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FAMILY ADOPTION PROGRAMME - 2024
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-
Step
1
of 2
Name of the Student
*
Registration Number
*
Batch
*
Student Contact Number
*
Name of the Student Coordinator
*
NAME OF THE HEAD OF THE FAMILY
*
ADDRESS
*
VILLAGE
*
TALUK
*
DISTRICT
*
AADHAR NUMBER
*
Name of the Scheme Eligible
*
Select
ABRK
ESI
Yeshaswini
Private Insurance
Any other Specify
Nil
Any other Scheme Specify
Phone No. of Family Head
*
TOTAL NUMBER OF FAMILY MEMBERS
*
Layout
Name of member - 1
*
Name of member - 2
*
Name of member - 3
*
Name of member - 4
*
Name of member - 5
Age
*
Age
*
Age
*
Age
*
Age
Any other data
*
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Layout
Name of Village
*
Name of head of family
*
Types of family
*
Select
Nuclear
Joint
SE status of family (Modified B.G. Prasad Classification)
Per capita monthly income
*
Upper class: 9098 and above
Upper middle class:4549-9097
Middle class: 9098 and above
Upper class: 9098 and above
Upper class: 9098 and above
Member-1 Details:
layout
Name of member
*
Weight
*
BP (diastolic)
*
DM Med
*
Select
yes
no
Age(Years)
*
Waist Circumference
*
Known HTN
*
yes
no
Hb%(5 to 49 yrs)
*
Gender
*
Select
Male
Female
Hip Circumference
*
HTN Med
*
Select
yes
no
RBS(>15 yrs)
*
Height
BP (systolic)
*
Known DM
*
Select
yes
no
Member-2 Details:
layout (copy)
Name of member
*
Weight
*
BP (diastolic)
*
DM Med
*
Select
yes
no
Age(Years)
*
Waist Circumference
*
Known HTN
*
yes
no
Hb%(5 to 49 yrs)
*
Gender
*
Select
Male
Female
Hip Circumference
*
HTN Med
*
Select
yes
no
RBS(>15 yrs)
*
Height
*
BP (systolic)
*
Known DM
*
Select
yes
no
Member-3 Details:
layout (copy) (copy)
Name of member
*
Weight
*
BP (diastolic)
*
DM Med
*
Select
yes
no
Age(Years)
*
Waist Circumference
*
Known HTN
*
yes
no
Hb%(5 to 49 yrs)
*
Gender
*
Select
Male
Female
Hip Circumference
*
HTN Med
*
Select
yes
no
RBS(>15 yrs)
*
Height
*
BP (systolic)
*
Known DM
*
Select
yes
no
Member-4 Details:
layout (copy) (copy) (copy)
Name of member
Weight
BP (diastolic)
DM Med
Select
yes
no
Age(Years)
Waist Circumference
Known HTN
yes
no
Hb%(5 to 49 yrs)
Gender
Select
Male
Female
Hip Circumference
HTN Med
Select
yes
no
RBS(>15 yrs)
Height
BP (systolic)
Known DM
Select
yes
no
Member-5 Details:
layout (copy) (copy) (copy) (copy)
Name of member
Weight
BP (diastolic)
DM Med
Select
yes
no
Age(Years)
Waist Circumference
Known HTN
yes
no
Hb%(5 to 49 yrs)
Gender
Select
Male
Female
Hip Circumference
HTN Med
Select
yes
no
RBS(>15 yrs)
Height
BP (systolic)
Known DM
Select
yes
no
Member-6 Details:
layout (copy) (copy) (copy) (copy) (copy)
Name of member
Weight
BP (diastolic)
DM Med
Select
yes
no
Age(Years)
Waist Circumference
Known HTN
yes
no
Hb%(5 to 49 yrs)
Gender
Select
Male
Female
Hip Circumference
HTN Med
Select
yes
no
RBS(>15 yrs)
Height
BP (systolic)
Known DM
Select
yes
no
Member-7 Details:
layout (copy) (copy) (copy) (copy) (copy) (copy)
Name of member
Weight
BP (diastolic)
DM Med
Select
yes
no
Age(Years)
Waist Circumference
Known HTN
yes
no
Hb%(5 to 49 yrs)
Gender
Select
Male
Female
Hip Circumference
HTN Med
Select
yes
no
RBS(>15 yrs)
Height
BP (systolic)
Known DM
Select
yes
no
Member-8 Details:
layout (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Name of member
Weight
BP (diastolic)
DM Med
Select
yes
no
Age(Years)
Waist Circumference
Known HTN
yes
no
Hb%(5 to 49 yrs)
Gender
Select
Male
Female
Hip Circumference
HTN Med
Select
yes
no
RBS(>15 yrs)
Height
BP (systolic)
Known DM
Select
yes
no
Member-9 Details:
layout (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Name of member
Weight
BP (diastolic)
DM Med
Select
yes
no
Age(Years)
Waist Circumference
Known HTN
yes
no
Hb%(5 to 49 yrs)
Gender
Select
Male
Female
Hip Circumference
HTN Med
Select
yes
no
RBS(>15 yrs)
Height
BP (systolic)
Known DM
Select
yes
no
Member-10 Details:
layout (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy) (copy)
Name of member
Weight
BP (diastolic)
DM Med
Select
yes
no
Age(Years)
Waist Circumference
Known HTN
yes
no
Hb%(5 to 49 yrs)
Gender
Select
Male
Female
Hip Circumference
HTN Med
Select
yes
no
RBS(>15 yrs)
Height
BP (systolic)
Known DM
Select
yes
no
Children less than 5 years
Field-1:
Layout (copy)
Name
*
Weight
Under weight
*
yes
no
Age
*
Stunted
Select
yes
no
Over weight
*
yes
no
Gender
*
Select
Male
Female
Wasted
Select
yes
no
Hb%
*
Height
Severely wasted
Select
yes
no
Field-2:
Layout (copy) (copy)
Name
*
Weight
*
Under weight
*
yes
no
Age
*
Stunted
*
Select
yes
no
Over weight
*
yes
no
Gender
*
Select
Male
Female
Wasted
*
Select
yes
no
Hb%
*
Height
*
Severely wasted
*
Select
yes
no
Field-3:
Layout (copy) (copy) (copy)
Name
Weight
Under weight
yes
no
Age
Stunted
Select
yes
no
Over weight
yes
no
Gender
Select
Male
Female
Wasted
Select
yes
no
Hb%
Height
Severely wasted
Select
yes
no
Field-4:
Layout (copy) (copy) (copy) (copy)
Name
Weight
Under weight
yes
no
Age
Stunted
Select
yes
no
Over weight
yes
no
Gender
Select
Male
Female
Wasted
Select
yes
no
Hb%
Height
Severely wasted
Select
yes
no
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