Mother Child Protection Card

Mother Photo
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(History of Past Pregnancy)
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Urine
·Oedema I Fundai iHeight/ FHS T.T. Injection 'Other .Remarks & Date of
tJ.tl. ao~~~ Symptoms Treabnent !Next Visit:
~~ftc..~ ~l!1o'>8~ SOf!JOJO~el) !Presentation
Date Weight B.P. ' Hbo/o
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(Check list for Special Care)
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High Risk
~~~6 ~~~ CSQi,dS:>oQ
Very High Risk
1. Instrumental delivery
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2. Eclampsia I~~~
3. PPH I CS~~cS~
4. 3 or more Abortions I
D
5. Previous Pre tenn delivery
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6. Still birth/Neonatal death I
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7. Caesarean Section I ~2:18<:1il~
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3 ~o~ ~~6.~ X~@o~~Ol
8. Other Obstetric Complications
D
0
0
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Primigravida under 15 years 0
l . Premature labour
~~~ K~~ 15~o11d~
2. Primigravida above 35 years I
~ot» ~ oS»oa ~ot>Ol oS6ne>
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2. Ante Partum Haemorrhage
~<6>~ tmotSJ 6~@o~o
0
0
3. Abnonnal Presentation
0
@)~~ K~~ 35~ou ~16
3. Age above 40 years I
ri~~ ~d:»~.J 4 0~011"Ec6
4. Pregnancy after prolonged
infertility (1 0 years)
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5. Fifth Pregnancy or greater
5
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8.
Th~eatened
abortion
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9. Other I Minor Complication
ad6
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5. Multipule Pregnancy
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0
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7. PIH
0
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8. Severe Anaemia
0
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9. Cardiac Disease
0
KJoa ed~al
10. Diabetes Mellitus
0
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7. Systemic Disease
eg,soD~ 6J1ldal
4. Intra Uterine Growth Retardation
~0~0 ~6.lK>6e) e5~~~~
~~e.>ex> 80" eDoei~oD ~~J.,OS
6. Hydramnios
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6. Height less than 145cm
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0
0
(6:,~~~0
11. Gestation exceeding 42 weeks0
42 eiJV6~a~ :OoE.NO
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NOTE :? e:s~ ~g ll~ ~~ii>o iltJ~e
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St~({u.) GO»~
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Date of Delivery & 'Time
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APGAR 1'mrn
IsMinutes
Normal
~/Weight
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SD~J @)a~ (Place):
lnstrumentaUCaesarian
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Abortion/Still Birth/Premature
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Stamp
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I Not Willing
91'6Cilo I Reason
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I TubeNas.
Oral Pills
I IUCO
I Coeloms
Others
....._ _ _ _ _ _ _ _ _ _ _ 5a~tS
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_ _ _ _ _ _ _ __...
GIRL : Weight-for-age • Birth to 5 years
.a:
(Aa per WHO Child Growth Stllnderda)
~~~ ~ l»eo.O - ~~
5
~ ~HH~~++~~~~~++~~~~
(S~
!2)·~· ' ''1011 51').
j ,~~~~~~P+~~~~~~~++~
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Fever
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10 lila I'INIIh OQntrO
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+Care During Illness+
E I 1 3 A ! I 1 t ! 10 II 11'
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Aet (~....,lllllltllllllrenl
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+•~ottto"' e~~ b~f~VJtS tl\~~Ul +
Ensure equal care for the girl child
6
BOY : Weight-for-age • Birth to 5 years
(Aa per WHO Child Growth Standards)
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.; Age (completed weeks, months and yeara)
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-~~~
B.C.G.
OPV-1
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OPV-2
OPV·3
Vitamin A
Vilam1nA
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~-------------------------
8
FORM N0.5
~~a.r~~tm
GOVERNMENTOFANDHRAPRADESH
.cs;S ~ ~~tm
Birth Certificate
. . . . . . . . . . . . . . . . . . . . .? . . . . . . . . . . . . . . . · · · - - - - . . . . . . . .. , . . _ . . . . . , . . . . . . . . ..
II..S . - ~ 1:. I" tl(t61clt~ llif Rll1hio -.1 . . . . Act 1969adltul8 13 f ~Alliin I'TIIk.!ih Rqto~twtum o(tltn~ IUld Llml!l ltllln !0'1111
~~~ ................................... !!q! ....................................... ~~
..... ' ............................................ (~:;)' ~~~) ~~ .S,6c; ~;o ~~~ ~Oo!Ji{)
-~ ~ ~.lfoe ~~ IM-~~ ~'1!>~6~~.
nus 1s to CC'Itlf) lbat the followiq mformallon bas been taken from the onginal record of buth, which 1s m the
register for •....•- ......................-....-.. (local area locaJ body) of Mandai ....................................
of Dastnct .........................................._..... of State Andhm Pradesh
~
Name
..
.. .. ......
~
Sex
~~
Date of Birth
~~
Place of Birth •
~1a&
.
Name of Mother ..
~~
Namt of father ·
~~~4~~
Addresl of lhe parents at the tune of 81nh of Child
4~~~~
P~tA~sofP~u
~~
Reg1stration No. _ .. - ..-·-·".. . _
~Date
of Regasttation
.. ____ "-
~
Rermarks .....--·---·"~--..·-~-~·-~
11'6~~
Date of Issue
.6 ~ -o.-o ~-~ tDOd:m ~~
Sagnature of the assuing authonty and addlftS
~I
Seal
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1
2
3
4
5
...
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ANM ~'~ (Signature)
~~~ (Signature)
3)
~~
;S4Sifo
~
(G.C.P.S.)
(~- ~ ~ 6:J. ~ ~ ~ !btDom ~h
~~. CJICL~ <~li'-~~ ~.
24,000/- ~ ~· ~ IP'otr~ C7ldbo 6:1-11 20.000/-)
~.,.0~~·
·-~~~~=
;$~~ (Signature)
~-------------------- 10 --------------------~
~I
Date
~/Diagnoais
Q
t>UJ I Treatment
~·I
~.e'll~
~o/
Sig.
~--------~------~ 11 ----------------~
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