indian council of medical research - Pondicherry University DSpace ...

Form to be filled up during follow up visits
Morbidity, School absenteism, Diet and Activities
Name Age Sex ID. No Date
Father's Name Sbeet House No. Msit No.
I. ILLNESS
1. History of Illness during the past two weeks Yes /No
2. If yes, the nature of illness
3. Details of illness
Fever \ Resp ! Dlarrhea \ Dysenteiy !
Abd.pain \ Headache \Eye \Ear ! Skin
Duratlon
Severity
mild \ mod \ sev
Hospital~sed Y\N
No, of school days lost
4. Type of health care rece~ved
I
Aliopalily
11 Home r~medy
III
iv
v
Faitti Heallng
Other systerns
No treatment
if (I) the11 a) Medicines avaliable at home b) Medlc~ties bought al petty shop c) Medlclnes bought
~n a pharmacy d) Med~c~ties prescrlbed by a Govl doctoi
e) Medlclnes prescrlbed by a prlvate doctor
5. lllterval between onset of illness and health care ............. days
6. Reasons for delay in health care, if any
2. Cost of illness
Medicine Rs. Consultation fees Rs. Travel Rs.
Investigation Rs.
Hospltnlisat~oll Rs.
Cost of accompanying person (Travel, food and loss of income) Rs.