Department of Community Medicine

Sheikh Bhikhari Medical College, Hazaribag

Logbook for Family Adoption Program

Name:………………………………………………………
Class Roll No. ……………………………………………..
Year of Admission: ……………………………………….
 Personal details
Recent Photo

Name of the student:

Date of admission to MBBS

Course:
College Roll No:

University Registration
Number:
Permanent Address:

E mail ID:

Mobile Number:

Blood group:

Hepatitis B vaccination
status:

COVID -19 vaccination:

AIM:
Family adoption program aims to provide an experiential learning
opportunity to Indian Medical graduates towards community based health care
and thereby enhance equity in health.

Objectives of the Program:

During the Medical UG training program, the learner should be able to:
1. Orient the learner towards primary health care
2. Create health related awareness within the community
3. Function as a first point of contact for any health issues within the community
4. Act as a conduit between the population and relevant health care facility
5. Generate and analyse related data for improving health outcomes and Evidence
based clinical practices.
TARGETS TO BE ACBIEYED BY STUDENTS:
Phase 1:
1. Rapport building and connect with the families
2. Learning communication skills and inspire trust building amongst families

3. Understand the dynamics of community set-up of that region

4. Mobilize families for participation in Screening programs
5. Undertake detailed family study and prepare the family diagnosis to identify diseases/ ill -
health/ malnutrition of allotted families/ risk factors / scope for health promotion

6. Formulate objectives to be achieved for each family.

Phase 2:
1. Continue active involvement to become the first doctor /reference point of the family by
continued active interaction
2. Ensure follow-up of members from adopted families for vaccination, growth monitoring and
promotion, menstrual hygiene, IFA prophylaxis, health lifestyle adoption, nutrition, vector control
measures, compliance to medications etc.
3. Work collaboratively with adopted families to achieve the formulated objectives
4. Inform families about ongoing government sponsored health related programs
5. Ensure appropriate referral of family members considering their choice for additional or annual
screening at higher health facilities.
Phase 3:
1. Work collaboratively with adopted families to achieve the formulated objectives
2. Observation of services delivered at the community level during Village Health Nutrition Days
(VHND), Community-based events (CBEs), Health and Wellness Centres (HWC) camps under the
different national health program
3. Build understanding regarding work of frontline workers (ANM, ASHA/USHA, AWW, MPW)
through interaction
4. Build understanding around intersectoral action for health through Local self- governing bodies,
NGOs, SHGs etc for health promotion

5. Undertake short term action projects for improving health in the adopted families or community
6. Analysis of their own involvement and impact on improving the health conditions in the adopted
families.
Final visit to have last round of active interaction with families -
prepare a report to be submitted to department addressing:
1. Improvement in overall health of the family
2. ImmunizationImprovement in general health
3. Sanitation,
4. De-addiction
5. Whether healthy lifestyles like reading good books. Sports/yoga
activities have been inculcated in the house-holds
6. Improvement in anaemia, tuberculosis control
7. Health awareness
8. Any other issues
9. Role of the student in supporting family during illness / medical
emergency
10. Social responsibility in the form of environment protection
programme in form of plantation drive (medicinal plants/trees)
cleanliness and sanitation drive with the initiative of the medical student
 Family Schedule

Name of the village/city ward:

Sub-centre: PHC:
FAMILY STUDIED
Head of the family:
Occupation:
Literacy status:

Map of area including household and community landmark

FAMILY PROFILE
Family size:
Family composition:
Sl. Name Relation with Age Sex Marital Education Occupation Income Medico
No head of (month status social
. family /years) conditions

Dependency ratio:
(Persons <15yrs+>65yrs/ Persons 15-64yrs = ……../…….)
Vital events in the family:

Vital events in last one Comment

year
Birth

Adoption

Marriage

Divorce

Death

SOCIOECONOMIC STATUS ASSESSMENT

Social status of the family
Religion: Hindu/ Muslim/ Christian/ Sikh/ Others (specify)
Caste: General/OBC/SC/ ST/ Others
Language known:
Literacy status of the family
Education level of head of family:
Literacy rate of the family: Male .....................%
Female ...................%
Total ......................%
Economic status
Total family income:
Per capita monthly income:
Socioeconomic class ............................ (According to modified BG Prasad classification)
Financial benefits from government: Old age pension/ Widow pension/ Ration
at subsidized rate/ Others
CULTURAL PRACTICES:

LIVING ENVIRONMENT
Perimeter of the house
Locality of house : Congested/Non-congested
Connectivity :
House
Tenure : Own/Rent
Type of house : Independent/Attached
Attachment : Side to side/Back to back/Both
Construction:
Type of house : Kaccha/Semipucca/Pucca
Roof : RCC/Tile/Zinc sheet/Thatched/Other
Floor : Mud/Cement/Stone/Others
Walls : Mud/Brick/Cement/Stone/Others
Lighting : Adequate/Inadequate
Ventilation : Adequate/Inadequate
Cross ventilation : Present/Absent
Dampness : Present/Absent
Overcrowding
Floor area of living room :
Doors and window space : Sufficient/Insufficient
Bath room : Separate/Not separate
Bathroom drainage : Open/Closed
Kitchen
Separate : Yes/No
Light : Adequate/Inadequate
Ventilation : Adequate/Inadequate
Fuel used : Wood/Coal/Gas/Others
Chullah used : Smokeless/Smoke letting
Smoke ventilation : Present/Absent
Raw and cooked food kept : Covered/Uncovered
Water supply
Water source : Well/River/Bore well/ Supply water
Pollution at source : Present/Absent
Distance to walk to get water :
Drinking water being used : Boiled/Filtered/Chlorinated/Not purified
Drinking water being used : Covered/Uncovered
Water storage and handling : ………………….
Separate bathroom : Present/ Absent
Water sufficiency : Yes/No
Waste disposal
Garbage disposal :
Waste water drainage :
Solid waste disposal :
Toilet : Present/Absent
Type of toilet : Sanitary/Insanitary
Toilet maintenance : Hygienic/Unhygienic
Biological environment

Psychosocial environment

DIETARY (NUTRITIONAL) ASSESSMENT

Food practices : Vegetarian/Non-vegetarian
Meal pattern : No. of meals/day
If non-vegetarian, how many times you take non-vegetarian
food:………………
In your daily schedule fruits are used: Yes/No
Availability of milk for children: Yes/No
Diet survey
Food items Family Nutrients available
consumption Protein Carbohydrate Fat Energy
per day (gm) (gm) (gm) (gm) (Kcal)
Cereals
Pulses
Vegetables
Milk
Oil and fat
Sugar and
jaggery
Others( Fruits)
Total
Calculation of Energy Consumption Unit (CU) for the family
Family Sex Occupational CU x Number of
member activities person
Adults Male Sedentary 1 x =
Male Moderate 1.2 x =
Male Heavy 1.6 x =
Female Sedentary 0.8 x =
Female Moderate 0.9 x =
Female Heavy 1.2 x =
Children (Age group)
1-3 0.4 x =
3-5 0.5 x =
5-7 0.6 x =
7-9 0.7 x =
9-12 0.8 x =
12-21 1.0 x =
Total consumption units of the family is
1 consumption unit=2400 Kcal/day

Calculation of Nutrient Requirements

Energy requirement of family=Family CU units x 2400 Kcal
= ......... x 2400 Kcal
= ............. Kcal

Nutrient Percentage of total energy Requirement(in gm)

required
Protein 15% of total energy
Fat 20% of total energy
Carbohydrate 65% of total energy
Assessment of Adequacy of Dietary Intakes
Balanced diet Family requirement Family Consumption Quantification
Deficient Excess
Protein

Carbohydrate

Fat

Energy

Inference:

FAMILY HEALTH PROFILE

Examine and interview all persons present during your visit, by giving priority
to vulnerable individuals. Briefly summarize the findings:
Pregnant women:
Family planning practices:
Seriously/Chronically ill persons:
Low birth weight child (as per immunization card):
Severely malnourished child:
Immunization status:
Maternal, neonatal or child death:
Severe anaemia:
Pneumonia, diarrhoea, vitamin A deficiency in child during last one year:
Health seeking behaviour of the family:
Awareness regarding availability of health services:
If yes, name that health outpost:
Nearest health care facility:
Preference of treatment-
In children:
In geriatric persons:
In pregnant women:
Others:
Reasons for preference:
Home Visit by Health Care Provider during sickness/pregnancy:

SUGGESTIONS FOR THE FAMILY STUDIED:

 Family Schedule

Name of the village/city ward:

Sub-centre: PHC:
FAMILY STUDIED
Head of the family:
Occupation:
Literacy status:

Map of area including household and community landmark

FAMILY PROFILE
Family size:
Family composition:
Sl. Name Relation with Age Sex Marital Education Occupation Income Medico
No head of (month status social
. family /years) conditions

Dependency ratio:
(Persons <15yrs+>65yrs/ Persons 15-64yrs = ……../…….)
Vital events in the family:

Vital events in last one Comment

year
Birth

Adoption

Marriage

Divorce

Death

SOCIOECONOMIC STATUS ASSESSMENT

Social status of the family
Religion: Hindu/ Muslim/ Christian/ Sikh/ Others (specify)
Caste: General/OBC/SC/ ST/ Others
Language known:
Literacy status of the family
Education level of head of family:
Literacy rate of the family: Male .....................%
Female ...................%
Total ......................%
Economic status
Total family income:
Per capita monthly income:
Socioeconomic class ............................ (According to modified BG Prasad classification)
Financial benefits from government: Old age pension/ Widow pension/ Ration
at subsidized rate/ Others
CULTURAL PRACTICES:

LIVING ENVIRONMENT
Perimeter of the house
Locality of house : Congested/Non-congested
Connectivity :
House
Tenure : Own/Rent
Type of house : Independent/Attached
Attachment : Side to side/Back to back/Both
Construction:
Type of house : Kaccha/Semipucca/Pucca
Roof : RCC/Tile/Zinc sheet/Thatched/Other
Floor : Mud/Cement/Stone/Others
Walls : Mud/Brick/Cement/Stone/Others
Lighting : Adequate/Inadequate
Ventilation : Adequate/Inadequate
Cross ventilation : Present/Absent
Dampness : Present/Absent
Overcrowding
Floor area of living room :
Doors and window space : Sufficient/Insufficient
Bath room : Separate/Not separate
Bathroom drainage : Open/Closed
Kitchen
Separate : Yes/No
Light : Adequate/Inadequate
Ventilation : Adequate/Inadequate
Fuel used : Wood/Coal/Gas/Others
Chullah used : Smokeless/Smoke letting
Smoke ventilation : Present/Absent
Raw and cooked food kept : Covered/Uncovered
Water supply
Water source : Well/River/Bore well/ Supply water
Pollution at source : Present/Absent
Distance to walk to get water :
Drinking water being used : Boiled/Filtered/Chlorinated/Not purified
Drinking water being used : Covered/Uncovered
Water storage and handling : ………………….
Separate bathroom : Present/ Absent
Water sufficiency : Yes/No
Waste disposal
Garbage disposal :
Waste water drainage :
Solid waste disposal :
Toilet : Present/Absent
Type of toilet : Sanitary/Insanitary
Toilet maintenance : Hygienic/Unhygienic
Biological environment

Psychosocial environment

DIETARY (NUTRITIONAL) ASSESSMENT

Food practices : Vegetarian/Non-vegetarian
Meal pattern : No. of meals/day
If non-vegetarian, how many times you take non-vegetarian
food:………………
In your daily schedule fruits are used: Yes/No
Availability of milk for children: Yes/No
Diet survey
Food items Family Nutrients available
consumption Protein Carbohydrate Fat Energy
per day (gm) (gm) (gm) (gm) (Kcal)
Cereals
Pulses
Vegetables
Milk
Oil and fat
Sugar and
jaggery
Others( Fruits)
Total
Calculation of Energy Consumption Unit (CU) for the family
Family Sex Occupational CU x Number of
member activities person
Adults Male Sedentary 1 x =
Male Moderate 1.2 x =
Male Heavy 1.6 x =
Female Sedentary 0.8 x =
Female Moderate 0.9 x =
Female Heavy 1.2 x =
Children (Age group)
1-3 0.4 x =
3-5 0.5 x =
5-7 0.6 x =
7-9 0.7 x =
9-12 0.8 x =
12-21 1.0 x =
Total consumption units of the family is
1 consumption unit=2400 Kcal/day

Calculation of Nutrient Requirements

Energy requirement of family=Family CU units x 2400 Kcal
= ......... x 2400 Kcal
= ............. Kcal

Nutrient Percentage of total energy Requirement(in gm)

required
Protein 15% of total energy
Fat 20% of total energy
Carbohydrate 65% of total energy
Assessment of Adequacy of Dietary Intakes
Balanced diet Family requirement Family Consumption Quantification
Deficient Excess
Protein

Carbohydrate

Fat

Energy

Inference:

FAMILY HEALTH PROFILE

Examine and interview all persons present during your visit, by giving priority
to vulnerable individuals. Briefly summarize the findings:
Pregnant women:
Family planning practices:
Seriously/Chronically ill persons:
Low birth weight child (as per immunization card):
Severely malnourished child:
Immunization status:
Maternal, neonatal or child death:
Severe anaemia:
Pneumonia, diarrhoea, vitamin A deficiency in child during last one year:
Health seeking behaviour of the family:
Awareness regarding availability of health services:
If yes, name that health outpost:
Nearest health care facility:
Preference of treatment-
In children:
In geriatric persons:
In pregnant women:
Others:
Reasons for preference:
Home Visit by Health Care Provider during sickness/pregnancy:

SUGGESTIONS FOR THE FAMILY STUDIED:

 Family Schedule

Name of the village/city ward:

Sub-centre: PHC:
FAMILY STUDIED
Head of the family:
Occupation:
Literacy status:

Map of area including household and community landmark

FAMILY PROFILE
Family size:
Family composition:
Sl. Name Relation with Age Sex Marital Education Occupation Income Medico
No head of (month status social
. family /years) conditions

Dependency ratio:
(Persons <15yrs+>65yrs/ Persons 15-64yrs = ……../…….)
Vital events in the family:

Vital events in last one Comment

year
Birth

Adoption

Marriage

Divorce

Death

SOCIOECONOMIC STATUS ASSESSMENT

Social status of the family
Religion: Hindu/ Muslim/ Christian/ Sikh/ Others (specify)
Caste: General/OBC/SC/ ST/ Others
Language known:
Literacy status of the family
Education level of head of family:
Literacy rate of the family: Male .....................%
Female ...................%
Total ......................%
Economic status
Total family income:
Per capita monthly income:
Socioeconomic class ............................ (According to modified BG Prasad classification)
Financial benefits from government: Old age pension/ Widow pension/ Ration
at subsidized rate/ Others
CULTURAL PRACTICES:

LIVING ENVIRONMENT
Perimeter of the house
Locality of house : Congested/Non-congested
Connectivity :
House
Tenure : Own/Rent
Type of house : Independent/Attached
Attachment : Side to side/Back to back/Both
Construction:
Type of house : Kaccha/Semipucca/Pucca
Roof : RCC/Tile/Zinc sheet/Thatched/Other
Floor : Mud/Cement/Stone/Others
Walls : Mud/Brick/Cement/Stone/Others
Lighting : Adequate/Inadequate
Ventilation : Adequate/Inadequate
Cross ventilation : Present/Absent
Dampness : Present/Absent
Overcrowding
Floor area of living room :
Doors and window space : Sufficient/Insufficient
Bath room : Separate/Not separate
Bathroom drainage : Open/Closed
Kitchen
Separate : Yes/No
Light : Adequate/Inadequate
Ventilation : Adequate/Inadequate
Fuel used : Wood/Coal/Gas/Others
Chullah used : Smokeless/Smoke letting
Smoke ventilation : Present/Absent
Raw and cooked food kept : Covered/Uncovered
Water supply
Water source : Well/River/Bore well/ Supply water
Pollution at source : Present/Absent
Distance to walk to get water :
Drinking water being used : Boiled/Filtered/Chlorinated/Not purified
Drinking water being used : Covered/Uncovered
Water storage and handling : ………………….
Separate bathroom : Present/ Absent
Water sufficiency : Yes/No
Waste disposal
Garbage disposal :
Waste water drainage :
Solid waste disposal :
Toilet : Present/Absent
Type of toilet : Sanitary/Insanitary
Toilet maintenance : Hygienic/Unhygienic
Biological environment

Psychosocial environment

DIETARY (NUTRITIONAL) ASSESSMENT

Food practices : Vegetarian/Non-vegetarian
Meal pattern : No. of meals/day
If non-vegetarian, how many times you take non-vegetarian
food:………………
In your daily schedule fruits are used: Yes/No
Availability of milk for children: Yes/No
Diet survey
Food items Family Nutrients available
consumption Protein Carbohydrate Fat Energy
per day (gm) (gm) (gm) (gm) (Kcal)
Cereals
Pulses
Vegetables
Milk
Oil and fat
Sugar and
jaggery
Others( Fruits)
Total
Calculation of Energy Consumption Unit (CU) for the family
Family Sex Occupational CU x Number of
member activities person
Adults Male Sedentary 1 x =
Male Moderate 1.2 x =
Male Heavy 1.6 x =
Female Sedentary 0.8 x =
Female Moderate 0.9 x =
Female Heavy 1.2 x =
Children (Age group)
1-3 0.4 x =
3-5 0.5 x =
5-7 0.6 x =
7-9 0.7 x =
9-12 0.8 x =
12-21 1.0 x =
Total consumption units of the family is
1 consumption unit=2400 Kcal/day

Calculation of Nutrient Requirements

Energy requirement of family=Family CU units x 2400 Kcal
= ......... x 2400 Kcal
= ............. Kcal

Nutrient Percentage of total energy Requirement(in gm)

required
Protein 15% of total energy
Fat 20% of total energy
Carbohydrate 65% of total energy
Assessment of Adequacy of Dietary Intakes
Balanced diet Family requirement Family Consumption Quantification
Deficient Excess
Protein

Carbohydrate

Fat

Energy

Inference:

FAMILY HEALTH PROFILE

Examine and interview all persons present during your visit, by giving priority
to vulnerable individuals. Briefly summarize the findings:
Pregnant women:
Family planning practices:
Seriously/Chronically ill persons:
Low birth weight child (as per immunization card):
Severely malnourished child:
Immunization status:
Maternal, neonatal or child death:
Severe anaemia:
Pneumonia, diarrhoea, vitamin A deficiency in child during last one year:
Health seeking behaviour of the family:
Awareness regarding availability of health services:
If yes, name that health outpost:
Nearest health care facility:
Preference of treatment-
In children:
In geriatric persons:
In pregnant women:
Others:
Reasons for preference:
Home Visit by Health Care Provider during sickness/pregnancy:

SUGGESTIONS FOR THE FAMILY STUDIED:

 MBBS Phase ……

Date of Visit Activities performed/Competencies Achieved Signature of Faculty

 MBBS Phase ……

Date of Visit Activities performed/Competencies Achieved Signature of Faculty

 MBBS Phase ……

Date of Visit Activities performed/Competencies Achieved Signature of Faculty

 MBBS Phase ……

Date of Visit Activities performed/Competencies Achieved Signature of Faculty

 MBBS Phase ……

Date of Visit Activities performed/Competencies Achieved Signature of Faculty

 MBBS Phase ……

Date of Visit Activities performed/Competencies Achieved Signature of Faculty

 MBBS Phase ……

Date of Visit Activities performed/Competencies Achieved Signature of Faculty

 MBBS Phase ……

Date of Visit Activities performed/Competencies Achieved Signature of Faculty

 Monitoring of Under 5 Child
(Students are expected to monitor health of U5 child in family)

Date of Name of Age (in Weight Height MUAC Immunization Remarks

Visit Child months) (Kg) (in cm) (in cm) status
 Monitoring of Under 5 Child
(Students are expected to monitor health of U5 child in family)

Date of Name of Age (in Weight Height MUAC Immunization Remarks

Visit Child months) (Kg) (in cm) (in cm) status
 Monitoring of Pregnant female
(Students are expected to monitor health of pregnant female in family; if any)
Name:
Age:
Head of Household:
Date of Visit Pulse BP Weight Immunization IFA and Ca Others Signature
Supplement (Faculty)
 Monitoring of Pregnant female
(Students are expected to monitor health of pregnant female in family; if any)
Name:
Age:
Head of Household:
Date of Visit Pulse BP Weight Immunization IFA and Ca Others Signature
Supplement (Faculty)
 Monitoring of Pregnant female
(Students are expected to monitor health of pregnant female in family; if any)
Name:
Age:
Head of Household:
Date of Visit Pulse BP Weight Immunization IFA and Ca Others Signature
Supplement (Faculty)
 Monitoring of Elderly individual
(Students are expected to monitor health of elderly individual in family; if any)
Name:
Age:
Head of Household:
Linked with any govt. programme for elderly:

Date of Visit Pulse BP Weight Co-morbid Compliance Others Signature

conditions for (Faculty)
medications
 Monitoring of Elderly individual
(Students are expected to monitor health of elderly individual in family; if any)
Name:
Age:
Head of Household:
Linked with any govt. programme for elderly:

Date of Visit Pulse BP Weight Co-morbid Compliance Others Signature

conditions for (Faculty)
medications
 Monitoring of Elderly individual
(Students are expected to monitor health of elderly individual in family; if any)
Name:
Age:
Head of Household:
Linked with any govt. programme for elderly:

Date of Visit Pulse BP Weight Co-morbid Compliance Others Signature

conditions for (Faculty)
medications
 Monitoring of Vital events in the family
(Students are expected to write details of any vital event in the family)

Date of Visit Vital Events Brief detail of event Faculty signature

 Monitoring of Vital events in the family
(Students are expected to write details of any vital event in the family)

Date of Visit Vital Events Brief detail of event Faculty signature

 IEC Activities/Health Camps
Date of Visit Activities performed/Students Observations Signature of Faculty
 LOGBOOK CERTIFICATE

This is to certify that the candidate Mr./Ms.…………………………………...

bearing University Roll no………………..admitted in the year…………………

in Sheikh Bhikhari Medical College (Formerly Called as Hazaribag Medical

College), Hazaribag has satisfactorily completed all assignments / requirements

mentioned in this logbook for MBBS course in the subject of Community

Medicine.

Signature of Faculty Signature and Seal

Name and Designation Head of Community

Medicine Department

Date:- ……/…../…….