This document contains a clinicosocial case proforma for under-5 children. It collects identification details, family history, birth history, feeding history, immunization history, dietary history, developmental history, environmental history, and general examination details. The proforma is used to assess cases presenting with common childhood illnesses like acute respiratory illness, diarrhea, and malnutrition. It allows for a medicosocial diagnosis and recommendations to be made at the individual, family, and community levels.

1. Clinicosocial Case
Under -5
Dr. Anuj Singh
Asst. Professor
Community Medicine Dept.
UIMS, Prayagraj

2. •Morbidity,
mortality pattern ?

5. •ARI
•Diarrhoea
•Malnutrition

7. Acute respiratory illness (ARI)

10. Medicosocial diagnosis

11. Recommendations
Individual level
Family level
Community level

12. Case of an Under 5 child: Proforma
1. Identification details-
• Name
• Age
• Gender
• Education
• Ouccupation
• Address
• Religion

13. • Type of family
• Family income
Socio-economic status:
1) Above / below poverty line
2) Socio-economic class
3) Dependency ration

14. BG prasad classification

15. • Details of the family and case of interest:
Sl no Name Age Relation to
HoH
Education Occupation

16. Chief complain-
• Fever
or
• Cough
or
• Diarrhoea
or
• Low weight
For so may
days……..

17. •Informant: Reliability?

18. Chief complain-
• Fever
or
• Cough
or
• Diarrhoea
or
• Low weight
Site ?
Onset ?
Duration ?
Progression ?
Radiation?
Relieving,Agravating factor ?
Other associated symptom ?
(Rash, vomiting,cough)

19. Personal history:
• Bladder, bowel
• Diet
• Appetite
• Sleep

20. • Family History
• Past History

21. Birth History
Full term, Pre term
Birth weight
Institutional / Home delivery
NVD / Caesarean delivery
Immediately cried or not

22. Feeding history
Age of EBF
Age of weaning

23. Immunization history:

24. Dietary history:
• 24 hrs. recall method
• Calorie deficit
• Protein deficit

25. Developmental History

26. Environmental history:
• Housing standard:
Floor, roof, wall, door, window
Lighting, ventilation
floor space, over crowding
• Kitchen:
Water supply
Fuel used for cooking
Smoke or smoke free
Disposal of waste

27. Biological Environment:
• Pets
• Cattle
• Mosquito breeding area
• Psychological Environment:
• Custom & health Practices

28. General Examination
• Pulse
• Respiration rate
• Temp
• Spo2
• Height
• Weight
• MUAC
P
I
C
C
L
E