FAMILY ADOPTION PROGRAMME

1
 Family Adoption Programme

Logbook
NAME OF THE STUDENT:

REGISTRATION NO:

YEAR OF STUDY:

2
 Certificate of Performance

This is to certify that Smt./Kum./Sri………………………………………………………….has satisfactorily

completed the course of Family Adoption Programme Prescribed by National Medical Commission
during the years …………….. to…………….

Signature of the Staff Signature of H.O.D

Date: Date:

University Register Number……………………….

3
 PREFACE

Around 65.5% of the population in India resides in rural areas whereas availability of health care facilities & services is skewed towards urban
areas. Though adequate healthcare supplies exist in the community, it is the access to healthcare to a rural citizen that is a major concern. Issues
like health literacy, ignorance about communicable and non-communicable diseases, means to reach healthcare facility, services, loss of daily
wages and workforce shortages are some of the barriers that limits timely and quality health related awareness and care leading to a scenario of
“Scarcity in abundance”. Hence this program is introduced to take measures to make healthcare more accessible to the rural and needy population
and impart community based and community-oriented training to budding healthcare professionals.

Aim:
Family adoption program aims to provide an experiential learning opportunity to Indian Medical Graduates towards community-based
healthcare and thereby enhance equity in health.

Objectives:
During the Medical UG training program, the learner should be able to:
• Orient the learner towards primary health care
• Create health related awareness within the community
• Function as a first point of contact for any health issues within the community
• Act as a conduit between the population and relevant health care facility
• Generate and analyse related data for improving health outcomes and evidence based clinical practices

4
 Competencies addressed in Family Adoption Programme

Competency Competencies
number
CM 1.5 Describe the application of interventions at various levels of
prevention
CM2.1 Describe the steps and perform clinico socio-cultural and demographic assessment of the
individual, family and community
CM2.2 Describe the socio-cultural factors, family (types), its role in health and disease &
demonstrate in a simulated environment the correct assessment of socio-economic status
CM 2.4 Describe social psychology, community behaviour and community relationship and their
impact on health and disease
CM 2.5 Describe poverty and social security measures and its relationship to health and disease
CM 3.5 Describe the standards of housing and the effect of housing on
health
CM 4.2 Describe the methods of organizing health promotion and education and counselling
activities at individual family and community settings
CM 5.2 Describe and demonstrate the correct method of performing a nutritional assessment of
individuals, families and the community by using the appropriate method
CM 5.4 Plan and recommend a suitable diet for the individuals and families based on local
availability of foods and economic status,

5
 LOG BOOK FOR FAMILY ADOPTION PROGRAMME

Instructions to the student:

1) The logbook is a record of the family adoption programme activities undertaken by the designated student, who would
be responsible for maintaining his/her logbook.

2) The student is responsible for getting the entries in the logbook verified by the faculty in-charge regularly

3) The entire data sheet may be prepared by every student and submitted latest by the end of the last visit for evaluation.

4) Progress notes must include demographic point and history recorded.

5) The logbook is a record of various activities by the student like:

● Visits to the adopted families
● Activities undertaken during each visit
● Follow-up activities undertaken
● Reflections of the students

6) The logbook is the record of work done by the candidate in field and should be verified by the college before submitting
the application of the students for the university examination.

6
 Details of Visits

Sl No Professional year Date of Visit Activity Done Sign of Faculty

7
 Details of Visits
Sl No Professional year Date of Visit Activity Done Sign of Faculty

8
 General Information of Village

1. Village Name:

2. Tahsil/ District:

3. Demographic details:

a. Total population:

b. Total no of households:

c. Male population

d. Female population

e. Under 5 population

4. Health services available:

5. Educational institutions:

6. Voluntary organizations:

7. Name of ASHA Worker:

8. Address & contact number of ASHA Worker:

9. Name of Anganwadi worker:

10. Address & contact number of Anganwadi Worker:

9
Village Map

10
MBBS 1st Professional Year

Family I

House plan

11
 Date of the visit:

Name of the Head of Family (HOF):

House number & Address:

Number of family members:

Socio-demographic details:

Sl. Name of the family Contact Age Sex Relationship Marital Education Occupation Income School name &
No. member number to HOF status class if studying
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Type of family: Nuclear/ Joint/ Three generation/ Broken

Total income of the family:
Socio-economic Status:
Member of any self-help group:
12
 Physical examination:
1st visit Follow up visit Follow up visit
Sl. Name of the Ht Wt BMI Waist BP Ht Wt BMI Waist BP Ht Wt BMI Waist BP
No family member (cm) (Kg) (Kg/ Hip (mm/ (cm) (Kg) (Kg/ Hip (mm/ (cm) (Kg) (Kg/ Hip (mm/
m 2) Ratio Hg) m 2) Ratio Hg) m2) Ratio Hg)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

13
Sl. No. Name of the family Hb Any other relevant investigations Immunization Hygiene
member (g/dl) status Oral/ General

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Vital events in the past 1 year:

Health insurance enrolled:

Any Addictions or substance use:

14
Medical History: Details of DM/HTN/ COPD/ Bronchial asthma / Cancer or any other illnesses present in the family may be entered in

this section)

Treatment history:

15
 Maternal & Child Health

(Details of Antenatal, Infant, Post Natal, Under 5yr, Adolescent cases, as appropriate to the given family may be entered in this section)

16
 Physical Environment
House:
[Own/ Rented], [Pucca/ Kuccha], [Overcrowding: Yes/No], [Ventilation: adequate/ inadequate],
[Lighting: adequate/inadequate], [Bathing Facilities: Yes/ No], [Washing facilities: Yes /No]

Kitchen:
[Smoke outlet: Yes/No], [Cooking platform: Yes/ No], [Storage of raw food: Sanitary/ Insanitary],
[Storage of cooked food; Sanitary/Insanitary], Type of fuel used: smokeless/ smoke forming
Surroundings of the house: Refuse/ Stagnant water collection/ Fly breeding places/ Human excreta/ Stray dogs / any other

Water supply:
Source: Surface water/ Underground/ Rainwater
Quantity for drinking purposes: Sufficient/ Insufficient Quantity for domestic purposes: Sufficient/ Insufficient
Method of storage: Sanitary/ Insanitary Method of disinfection:
Method of consumption: Sanitary/ Insanitary

Solid waste management:

Segregation of dry & wet waste: Yes/ No
Method of disposal:

Excreta Management:
Lavatory: Exclusive/ Shared/ Public
Water supply in the lavatory: Yes/ No Open air defecation: Yes/ No

17
Remarks of Family I:

18
Family II

House plan

19
 Date of the visit:

Name of the Head of Family (HOF):

House number & Address:

Number of family members:

Socio-demographic details:

Sl. Name of the family Contact Age Sex Relationship Marital Education Occupation Income School name &
No. member number to HOF status class if studying
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Type of family: Nuclear/ Joint/ Three generation/ Broken

Total income of the family:
Socio-economic Status:
Member of any self-help group:
20
 Physical examination:

1st visit Follow up visit Follow up visit

Sl. Name of the Ht Wt BMI Waist BP Ht Wt BMI Waist BP Ht Wt BMI Waist BP
No family member (cm) (Kg) (Kg/ Hip (mm/ (cm) (Kg) (Kg/ Hip (mm/ (cm) (Kg) (Kg/ Hip (mm/
m 2) Ratio Hg) m 2) Ratio Hg) m2) Ratio Hg)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

21
Sl. No. Name of the family Hb Any other relevant investigations Immunization Hygiene
member (g/dl) status Oral/ General

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Vital events in the past 1 year:

Health insurance enrolled:

Any Addictions or substance use:

22
Medical History: Details of DM/HTN/ COPD/ Bronchial asthma / Cancer or any other illnesses present in the family may be entered in

this section)

Treatment history:

23
 Maternal & Child Health

(Details of Antenatal, Infant, Post Natal, Under 5yr, Adolescent cases, as appropriate to the given family may be entered in this section)

24
 Physical Environment
House:
[Own/ Rented], [Pucca/ Kuccha], [Overcrowding: Yes/No], [Ventilation: adequate/ inadequate],
[Lighting: adequate/inadequate], [Bathing Facilities: Yes/ No], [Washing facilities: Yes /No]

Kitchen:
[Smoke outlet: Yes/No], [Cooking platform: Yes/ No], [Storage of raw food: Sanitary/ Insanitary],
[Storage of cooked food; Sanitary/Insanitary], Type of fuel used: smokeless/ smoke forming
Surroundings of the house: Refuse/ Stagnant water collection/ Fly breeding places/ Human excreta/ Stray dogs / any other

Water supply:
Source: Surface water/ Underground/ Rainwater
Quantity for drinking purposes: Sufficient/ Insufficient Quantity for domestic purposes: Sufficient/ Insufficient
Method of storage: Sanitary/ Insanitary Method of disinfection:
Method of consumption: Sanitary/ Insanitary

Solid waste management:

Segregation of dry & wet waste: Yes/ No
Method of disposal:

Excreta Management:
Lavatory: Exclusive/ Shared/ Public
Water supply in the lavatory: Yes/ No Open air defecation: Yes/ No
25
Remarks of Family II:

26
Family III

House plan

27
 Date of the visit:

Name of the Head of Family (HOF) :

House number & Address:

Number of family members:

Socio-demographic details:

Sl. Name of the family Contact Age Sex Relationship Marital Education Occupation Income School name &
No. member number to HOF status class if studying
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Type of family: Nuclear/ Joint/ Three generation/ Broken

Total income of the family:
Socio-economic Status:
Member of any self-help group:
28
 Physical examination:

1st visit Follow up visit Follow up visit

Sl. Name of the Ht Wt BMI Waist BP Ht Wt BMI Waist BP Ht Wt BMI Waist BP
No family member (cm) (Kg) (Kg/ Hip (mm/ (cm) (Kg) (Kg/ Hip (mm/ (cm) (Kg) (Kg/ Hip (mm/
m 2) Ratio Hg) m 2) Ratio Hg) m2) Ratio Hg)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

29
Sl. No. Name of the family Hb Any other relevant investigations Immunization Hygiene
member (g/dl) status Oral/ General

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Vital events in the past 1 year:

Health insurance enrolled:

Any Addictions or substance use:

30
Medical History: Details of DM/HTN/ COPD/ Bronchial asthma / Cancer or any other illnesses present in the family may be entered in

this section)

Treatment history:

31
 Maternal & Child Health

(Details of Antenatal, Infant, Post Natal, Under 5yr, Adolescent cases, as appropriate to the given family may be entered in this section)

32
 Physical Environment
House:
[Own/ Rented], [Pucca/ Kuccha], [Overcrowding: Yes/No], [Ventilation: adequate/ inadequate],
[Lighting: adequate/inadequate], [Bathing Facilities: Yes/ No], [Washing facilities: Yes /No]

Kitchen:
[Smoke outlet: Yes/No], [Cooking platform: Yes/ No], [Storage of raw food: Sanitary/ Insanitary],
[Storage of cooked food; Sanitary/Insanitary], Type of fuel used: smokeless/ smoke forming
Surroundings of the house: Refuse/ Stagnant water collection/ Fly breeding places/ Human excreta/ Stray dogs / any other

Water supply:
Source: Surface water/ Underground/ Rainwater
Quantity for drinking purposes: Sufficient/ Insufficient Quantity for domestic purposes: Sufficient/ Insufficient
Method of storage: Sanitary/ Insanitary Method of disinfection:
Method of consumption: Sanitary/ Insanitary

Solid waste management:

Segregation of dry & wet waste: Yes/ No
Method of disposal:

Excreta Management:
Lavatory: Exclusive/ Shared/ Public
Water supply in the lavatory: Yes/ No Open air defecation: Yes/ No

33
Remarks of Family III:

34
 Environmental Protection & Sustenance Activities
(Add photos)

Date:

Summary:

35
 Health Camp
(Add photos)

Date:

Summary:

36
 Health Education
(Add Photos)
Date:

Summary:

37
 Reflections

Positive outcomes:

Challenges faced:

Actions to be taken for next year:

38
 MBBS 2nd Professional Year

Family I

Date of the visit:

Name of Head of Family (HOF):

Follow up remarks on Socio-demographic details:

Follow Up Medical & MCH Details:

39
 Follow up examination:

Follow up visit Follow up visit Follow up visit

Sl. Name of the Ht Wt BMI Waist BP Ht Wt BMI Waist BP Ht Wt BMI Waist BP
No family member (cm) (Kg) (Kg/ Hip (mm/ (cm) (Kg) (Kg/ Hip (mm/ (cm) (Kg) (Kg/ Hip (mm/
m 2) Ratio Hg) m 2) Ratio Hg) m2) Ratio Hg)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

40
Sl. No. Name of the family Hb Any other relevant investigations Immunization Hygiene
member (g/dl) status Oral/ General

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

41
 Dietary Assessment
▪ Type of diet/Staple diet
▪ Cooking practices
▪ Food fads/ food taboo

Food groups consumed Weekly Daily Remarks

consumption in consumption in
gm gm

Total consumption unit required for the family:

Total calorie required for the family:

Total calorie intake observed:

42
Remarks of Family I:

43
 Family II

Date of the visit:

Name of Head of Family (HOF):

Follow up remarks on Socio-demographic details:

Follow Up Medical & MCH Details:

44
 Follow up examination:

Follow up visit Follow up visit Follow up visit

Sl. Name of the Ht Wt BMI Waist BP Ht Wt BMI Waist BP Ht Wt BMI Waist BP
No family member (cm) (Kg) (Kg/ Hip (mm/ (cm) (Kg) (Kg/ Hip (mm/ (cm) (Kg) (Kg/ Hip (mm/
m 2) Ratio Hg) m 2) Ratio Hg) m2) Ratio Hg)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

45
Sl. No. Name of the family Hb Any other relevant investigations Immunization Hygiene
member (g/dl) status Oral/ General

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

46
 Dietary Assessment
▪ Type of diet/Staple diet
▪ Cooking practices
▪ Food fads/ food taboo

Food groups consumed Weekly Daily Remarks

consumption in consumption in
gm gm

Total consumption unit required for the family:

Total calorie required for the family:

Total calorie intake observed:

47
Remarks of Family II:

48
 Family III

Date of the visit:

Name of Head of Family (HOF):

Follow up remarks on Socio-demographic details:

Follow Up Medical & MCH Details:

49
 Follow up examination:

Follow up visit Follow up visit Follow up visit

Sl. Name of the Ht Wt BMI Waist BP Ht Wt BMI Waist BP Ht Wt BMI Waist BP
No family member (cm) (Kg) (Kg/ Hip (mm/ (cm) (Kg) (Kg/ Hip (mm/ (cm) (Kg) (Kg/ Hip (mm/
m 2) Ratio Hg) m 2) Ratio Hg) m2) Ratio Hg)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

50
Sl. No. Name of the family Hb Any other relevant investigations Immunization Hygiene
member (g/dl) status Oral/ General

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

51
 Dietary Assessment
▪ Type of diet/Staple diet
▪ Cooking practices
▪ Food fads/ food taboo

Food groups consumed Weekly Daily Remarks

consumption in consumption in
gm gm

Total consumption unit required for the family:

Total calorie required for the family:

Total calorie intake observed:

52
Remarks of Family III:

53
 Environmental Protection & Sustenance Activities

(Add photos)

Date:

Summary:

54
 Health Camp
Date:

Summary:

Photos:

55
 Health Education
Date:

Summary:

Photos:

56
 Reflections

Positive outcomes:

Challenges faced:

Actions to be taken for next year:

57
 MBBS 3rd Professional Year

Family I

Date of the visit:

Name of Head of Family (HOF):

Follow up remarks on Socio-demographic details:

Follow Up Medical & MCH Details:

58
 Follow up examination:

Follow up visit Follow up visit Follow up visit

Sl. Name of the Ht Wt BMI Waist BP Ht Wt BMI Waist BP Ht Wt BMI Waist BP
No family member (cm) (Kg) (Kg/ Hip (mm/ (cm) (Kg) (Kg/ Hip (mm/ (cm) (Kg) (Kg/ Hip (mm/
m 2) Ratio Hg) m 2) Ratio Hg) m2) Ratio Hg)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

59
Sl. No. Name of the family Hb Any other relevant investigations Immunization Hygiene
member (g/dl) status Oral/ General

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

60
 Nutritional Assessment of the Family

Sl. No Clinical features Family Member

1 2 3 4 5
1. General appearance: Normal built/Thin built/ Sickly

2. Hair: Normal/ Dull and dry/Dyspigmented / Thin &

sparse/Easily pluckable / Flag sign
3. Eyes: Conjunctiva – Normal/ Dry on exposure for ½
min/ Dry and wrinkled/ Bitot's spots/ Brown
pigmentation/ Angular conjunctivitis / Pale conjunctiva
Cornea – Normal/ Dry/ Hazy or opaque
4. Lips: Normal/Angular stomatitis/Cheilosis

5. Tongue: Normal/Pale and flabby/ Red and raw/

Fissured/ Geographic tongue
6. Teeth: Mottled enamel/ Carries/Attrition/Bleeding

7. Gums: Normal/ Bleeding

8. Glands: Thyroid enlargement/ Parotid enlargement

9. Skin: Normal/ dry and scaly/ follicular hyperkeratosis

10. Nails: Koilonychia

11. Oedema: Independent parts

12. Rachitic changes: Knock-knees or bow legs/epiphyseal

enlargement/ beading of the ribs/ pigeon chest
61
 Dietary Assessment
▪ Type of diet/Staple diet
▪ Cooking practices
▪ Food fads/ food taboo
Food groups consumed Weekly Daily Remarks
consumption in consumption in
gm gm

Total consumption unit required for the family:

Total calorie required for the family:

Total calorie intake observed:

62
KAP assessment:
a. Knowledge: Adequate/ Inadequate
b. Attitude: Favourable/ Unfavourable
c. Practice: Rational/ Irrational

Remarks of Family I:

63
 Family II

Date of the visit:

Name of Head of Family (HOF):

Follow up remarks on Socio-demographic details:

Follow Up Medical & MCH Details:

64
 Follow up examination:

Follow up visit Follow up visit Follow up visit

Sl. Name of the Ht Wt BMI Waist BP Ht Wt BMI Waist BP Ht Wt BMI Waist BP
No family member (cm) (Kg) (Kg/ Hip (mm/ (cm) (Kg) (Kg/ Hip (mm/ (cm) (Kg) (Kg/ Hip (mm/
m 2) Ratio Hg) m 2) Ratio Hg) m2) Ratio Hg)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

65
Sl. No. Name of the family Hb Any other relevant investigations Immunization Hygiene
member (g/dl) status Oral/ General

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

66
 Nutritional Assessment of the Family

Sl. No Clinical features Family Member

1 2 3 4 5
1. General appearance: Normal built/Thin built/ Sickly

2. Hair: Normal/ Dull and dry/Dyspigmented / Thin &

sparse/Easily pluckable / Flag sign
3. Eyes: Conjunctiva – Normal/ Dry on exposure for ½
min/ Dry and wrinkled/ Bitot's spots/ Brown
pigmentation/ Angular conjunctivitis / Pale conjunctiva
Cornea – Normal/ Dry/ Hazy or opaque
4. Lips: Normal/Angular stomatitis/Cheilosis

5. Tongue: Normal/Pale and flabby/ Red and raw/

Fissured/ Geographic tongue
6. Teeth: Mottled enamel/ Carries/Attrition/Bleeding

7. Gums: Normal/ Bleeding

8. Glands: Thyroid enlargement/ Parotid enlargement

9. Skin: Normal/ dry and scaly/ follicular hyperkeratosis

10. Nails: Koilonychia

11. Oedema: Independent parts

12. Rachitic changes: Knock-knees or bow legs/epiphyseal

enlargement/ beading of the ribs/ pigeon chest
67
 Dietary Assessment
▪ Type of diet/Staple diet
▪ Cooking practices
▪ Food fads/ food taboo
Food groups consumed Weekly Daily Remarks
consumption in consumption in
gm gm

Total consumption unit required for the family:

Total calorie required for the family:

Total calorie intake observed:

68
KAP assessment:
a. Knowledge: Adequate/ Inadequate
b. Attitude: Favourable/ Unfavourable
c. Practice: Rational/ Irrational

Remarks of Family II:

69
 Family III

Date of the visit:

Name of Head of Family (HOF):

Follow up remarks on Socio-demographic details:

Follow Up Medical & MCH Details:

70
 Follow up examination:

Follow up visit Follow up visit Follow up visit

Sl. Name of the Ht Wt BMI Waist BP Ht Wt BMI Waist BP Ht Wt BMI Waist BP
No family member (cm) (Kg) (Kg/ Hip (mm/ (cm) (Kg) (Kg/ Hip (mm/ (cm) (Kg) (Kg/ Hip (mm/
m 2) Ratio Hg) m 2) Ratio Hg) m2) Ratio Hg)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

71
Sl. No. Name of the family Hb Any other relevant investigations Immunization Hygiene
member (g/dl) status Oral/ General

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

72
 Nutritional Assessment of the Family

Sl. No Clinical features Family Member

1 2 3 4 5
1. General appearance: Normal built/Thin built/ Sickly

2. Hair: Normal/ Dull and dry/Dyspigmented / Thin &

sparse/Easily pluckable / Flag sign
3. Eyes: Conjunctiva – Normal/ Dry on exposure for ½
min/ Dry and wrinkled/ Bitot's spots/ Brown
pigmentation/ Angular conjunctivitis / Pale conjunctiva
Cornea – Normal/ Dry/ Hazy or opaque
4. Lips: Normal/Angular stomatitis/Cheilosis

5. Tongue: Normal/Pale and flabby/ Red and raw/

Fissured/ Geographic tongue
6. Teeth: Mottled enamel/ Carries/Attrition/Bleeding

7. Gums: Normal/ Bleeding

8. Glands: Thyroid enlargement/ Parotid enlargement

9. Skin: Normal/ dry and scaly/ follicular hyperkeratosis

10. Nails: Koilonychia

11. Oedema: Independent parts

12. Rachitic changes: Knock-knees or bow legs/epiphyseal

enlargement/ beading of the ribs/ pigeon chest
73
 Dietary Assessment
▪ Type of diet/Staple diet
▪ Cooking practices
▪ Food fads/ food taboo
Food groups consumed Weekly Daily Remarks
consumption in consumption in
gm gm

Total consumption unit required for the family:

Total calorie required for the family:

Total calorie intake observed:

74
KAP assessment:
a. Knowledge: Adequate/ Inadequate
b. Attitude: Favourable/ Unfavourable
c. Practice: Rational/ Irrational

Remarks of Family III:

75
 Environmental Protection & Sustenance Activities
(Add Photos)

Date:

Summary:

76
 Health Camp
(Add photos)
Date:

Summary:

77
 Health Education
(Add photos)
Date:

Summary:

78
 Reflections

Positive outcomes:

Challenges faced:

Actions to be taken:

79
Final Report

80
81
82
83