Standards for Female and Male Sterilization Services - STATE ...

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56Standards for female and male Sterilization servicesB. Obstetrics history (for female acceptors)No. of spontaneous abortions .................................................................................................No. of induced abortions .................................................................................................Currently lactatingYes...........................................................................................No...........................................................................................AmenorrhoeicYes...........................................................................................No...........................................................................................Whether pregnantYes...........................................................................................No...........................................................................................If yes (no. of weeks of pregnancy)...................................C. Contraceptive historyHave you or your spouse ever used anycontraception?Are you or your spouse currently using anycontraception, or have you or your spouse used anycontraception during the last 6 months?Yes...........................................................................................No...........................................................................................None.......................................................................................IUCD......................................................................................Condoms................................................................................Oral pills.................................................................................Any other (specify)...............................................................D. Medical historyRecent medical illnessPrevious surgeryAllergies to medicationBleeding disorderAnaemiaDiabetesJaundice or liver disorderRTI/STI/PIDConvulsive disorderTuberculosisMalariaAsthmaHeart diseaseYes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................
Standards for female and male Sterilization services 57HypertensionMental illnessSexual problemsProstatitisEpididymitisH/O blood transfusionGynaecological problemsCurrently on medication (if yes, specify)Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Yes.............................................. No...................................................Comments........................................................................................................................................................................................................................................................................................................................................................................................................................................................................................Physical ExaminationBP........................................... Pulse...........................................Temperature........................................LungsHeartAbdomenNormal..................................... Abnormal..........................................Normal..................................... Abnormal..........................................Normal..................................... Abnormal..........................................3. Local examinationMale sterilizationSkin of scrotumTestisEpididymisHydroceleVaricoceleHerniaVas deferensBoth vas palpableNormal..................................................... Abnormal.....................................................Normal..................................................... Abnormal.....................................................Normal..................................................... Abnormal.....................................................Yes............................................................. No.................................................................Yes............................................................. No.................................................................Yes............................................................. No.................................................................Normal..................................................... Abnormal.....................................................Yes............................................................. No.................................................................
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DR. (SMT.) M.S. JayalakshmiDeputy C
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