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Appendices

The appendix 1.

St.-Petersburg state pediatric medical akayodemija

The formalized questionnaire of primary diagnostics

St.-Petersburg, 1995

DEAR PARENTS!

The earnest entreaty attentively to read the questionnaire and accurately to fill it, obvoyodja (underlining) positive or negative answers to the put questions, entering the necessary information.

Surname, name of the child ____________________________________

Date of birth __________________________________________

School (day nursery-gardens), class (group) ______________________

Residence _______________________________________

Site N ___ is served by children's out-patient department N ___,

The block "GENERAL DATA"

01. Age of the child at the moment of filling карты:лет __ month __ 02. The Sex of a child: the 1-boy, the 2-girl 03. Growth at a birth __________________

04. Weight at a birth _________

05. A place of work and a post of mother ______________________

06. A place of work and a post of the father ________________________

07. Number of acute diseases for last year before inspection (including those, on

To which occasion you have not addressed to the doctor) ____

08. Number of days of illness of the child for last year (total) _____

09. List diseases for last year as their frequency

10. A nationality of mother

The father _______________________________

11. Duration of residing in given district (years):

Mothers __________ the father _______________ the child ____________

The block "RISK MEDIKO-SOCIAL FACTORS" 1. Antenatalnyj the period, the labours, the first year of a life

01. Whether there were abortions at mother till a birth of the child?... Yes is not present

02. Whether smoked mother regularly to or during pregnancy?........................ Yes is not present

03. Whether the father in the presence of the pregnant wife smoked?... Yes is not present

04. Whether mother alcohol to or during pregnancy abused?......... Yes is not present

05. Whether the father alcohol till a birth of the given child abused?............ Yes is not present 06. Whether became perceptible at mother during pregnancy an early toxicosis (vomiting, an icterus, an itch), a late toxicosis (edemas, fiber in urine, pressure rising), other complications

Pregnancy?....................... Yes is not present

07. The age of mother by the moment of a birth of the child was more senior 35 years?............. Yes is not present 08. The age of mother by the moment of a birth of the child was

More youngly 18 years?................................. Yes is not present

09. The age of the father by the moment of a birth of the child was

40 years are more senior?.................................. Yes is not present

10. The child was born not full-term? Yes is not present

11. The child was born with a birth trauma, in an asphyxia,

With an icterus of newborns, with other complications? Yes is not present

12. Whether work of mother has been bound to the industrial

Harmfulnesses for a year before pregnancy?. Yes is not present

13. Before conception (within a year) whether there was a work of the father

It is bound to professional harmfulnesses?........ Yes is not present

14. The child has been separated from a breast till 2 months? Yes is not present

15.

Whether you tried (or wished) to get rid from

Pregnancy the given child?.................... Yes is not present

16. If your child not the first-born, whether that was an interval

Between a birth of the given child and previous

Less than 2 years?................................... Yes is not present

17. Whether mother till a birth of the given child suffered

Chronic diseases?........................ Yes is not present

18. Whether were at the father till a birth of the given child

Chronic diseases?........................ Yes is not present

2. The family characteristic

01. Whether your family has the privileges provided for

Large families............................... Yes is not present

02. The child is brought up without the father (without mother)?... Yes is not present

03. Whether the family tests the serious material

Difficulties?.................................. Yes is not present

04. Whether you consist on the account for improvement of the housing

Conditions?......................................... Yes is not present

05. Whether adults in the presence of the child smoke?.... Yes is not present

06. Whether mother, the father abuse alcohol?...... Yes is not present

07. Whether you consider, that your child does not observe

Sleep pattern, walks, a food?................... Yes is not present

08. Whether the schoolboy visits group of the prolonged day?... Yes is not present 09. Whether your child is engaged in activly sports or

The child has other physical overloads? Yes is not present

10. Whether your child in addition (more is engaged

5 ch in a week) out of the school program (music,

Tongues, etc.)................................ Yes is not present

11. Whether there are in your family invalids, oncologic

The patients sick of mental diseases,

"Lying" patients?............................... Yes is not present

12. Whether there were in a life of the child serious stressful situations

(Mors of the loved one, accident, etc.)?. Yes is not present 13. Whether you noticed, that your child smokes, uses

Alcohol, narcotics?............................ Yes is not present

The block "the SOCIALLY-HYGIENIC CHARACTERISTIC of the CHILD And the FAMILY In WHICH IT is brought up"

01. Age of mother at the moment of card filling (full years).........

02. Number of children in a family, including the given child?.........

03. How many abortions you have made for last 3 years?..... From them: on mediyotsinskim to indications.................................................................................................

Misbirths and abortions..............................

At desire (in medical institutions)...........................

At desire (out of medical institutions).........................

04. Abortions at will have been bound basically with:

1 - a bad state of health;

2 - is material-household difficulties;

3 - family disorders, absence of the husband;

4 - employment on manufacture, study;

5 - uncertainty in tomorrow;

6 - fear for a state of health of the future child because of negative ecological influence;

7 - fear of sorts;

05. As you consider:

How many children should be in a family in general?.....

How many children you would like to have in the family?.....

How many children in a family you really plan to have, including already available?.....

06. If you any more do not wish to have children it is bound with:

1 - a bad state of health;

2 - is material-household difficulties;

3 - family disorders, absence of the husband;

4 - employment on manufacture, study;

5 - uncertainty in tomorrow;

6 - fear for a state of health of the future child because of negative ecological influence;

7 - fear of sorts;

07. Living conditions in which you live,

You completely satisfy?.......................... Yes... Is not present if is not present, it is bound with:

1 - a floor space disadvantage;

2 - absence of necessary municipal conveniences;

3 - a bad condition of habitation (humidity, low light exposure, bad heating, etc.);

4 - presence of neighbours in municipal apartment;

08. The material income of your family:

1 - money does not suffice even on a food;

2 - money suffices only on a food;

3 - money suffices on a food and on acquisition of essential commodities;

4 - money suffices for a normal life;

5 - problems with money are not present, we are well off.

09. As it is frequent your family uses following products: (against each kind of products put the necessary code number: 1 - some times in day; 2 - daily; 3 - neyoskolko once a week; 4 - some times in a month; 5 - is more rare than 1 time a month)

Meat and meat products...

Milk and milk products...

Vegetables...

Fish and fish products...

Eggs...

Fruit...

Oil...

Macaroni and pasta...

Porridges...

10. How a food of your family for last 2 years has changed? (Against each kind of products put the necessary code number: 1 - have ceased to use in general; 2 - upotyorebljat became more rare; 3 - began to use more often; 4 - has not changed)

Meat and meat products...

Milk and milk products...

Vegetables...

Fish and fish products...

Eggs...

Fruit...

Oil...

Macaroni and pasta...

Porridges...

11. These changes in quality of a food are bound with:

1 - material difficulties;

2 - absence of products on sale;

3 - uncertainty in ecological cleanliness of products;

4 - diet observance;

12. Whether you pay attention at purchase of products to the place of their manufacture:

1 - I do not pay attention;

2 - I try not to buy the products made in the Byelorussian

These, Bryansk region, in Ukraine;

3 - I pay attention, but I buy products of any a prorecension

stva.

13. What kinds of products you try to limit because of fear for them ekologicheyoskuju cleanliness:

1 - meat and meat products;

2 - milk products;

3 - vegetables, fruit;

4 - fish;

5 - eggs;

6 - oil;

7 - groats;

8 - unboiled water;

9 - I do not limit.

14. List those products which, in your opinion, can render neblagoyoprijatnoe influence on your health because of ecological pollution:................................................................................................

15. As you estimate an ecological situation in region (disregarding a climate), where do you live:

1 good;

2 bad;

3 I do not know

16. If you consider, that an ecological situation in region, where do you live, bad, because of fear for health you:

1 - limit stay of the child in the street;

2 - try not to sunbathe;

3 - try not to bathe in area reservoirs;

4 - do not use in berry nutrition, mushrooms;

5 - do not use the fish caught in reservoirs of area;

6 - try not to leave for a city;

7 - do not drink unboiled water;

8 - try to spend holiday in other regions; 17. Whether you consider, what possess enough the objective information on an ecological situation in region?

1 - yes;

2 - is not present.

18. Whether you wish to move on a constant residence to other region of the country? 1 - yes;

2 - is not present.

19. Your child:

It is quiet, friendly - 1;

It is mobile, nesobran - 2; it is irritable, aggressive - 3;

Flaccid, suppressed - 4; sociable - 5;

Closed - 6.

20. Whether important for your child opinion of associates?

1 - yes;

2 - is not present

21. Whether the feeling of confidence is inherent in the child?

1 - yes;

2 - is not present

22. Mutual relations with contemporaries: good, friendly - 1;

Bad, strained - 2;

Avoids dialogue - 3

23. Study of the schoolboy (excellent - 1; good - 2; satisfactory - 3; bad - 4):

- On the humanities (the literature, history, natural sciences, etc.)...

- On the exact sciences (arithmetics, mathematics)...

24. According to mother, whether on the development the child lags behind contemporaries:

1 - does not lag behind;

2 - lags behind for 1 year;

3 - lags behind considerably.

The block "OBSERVATION At EXPERTS"

Whether your child on the account at listed below experts (unitary consultations in attention not to accept) consists?

01.у the allergist/lung specialist.................... Yes is not present

02.у the nephrologist/urologist........................... Yes is not present

03.у the neuropathologist/neuropsychiatrist................ Yes is not present

04.у otorinolaringologa/ENT-doctor............... Yes is not present

05.у the surgeon/orthopedist............................ Yes is not present

06.у the gastroenterologist/proctologist.................. Yes is not present

07.у the dermatologist................................ Yes is not present

08.у the cardiologist/kardiorevmatologa.............. Yes is not present

09.у the endocrinologist................................ Yes is not present

10.у the ophthalmologist/oculist....................... Yes is not present

11. At the oncologist yes is not present

12. At any other expert (specify at what)...

13. Whether you consider, that your child should be observed by someone from experts yes is not present

The block "HEREDITARY FACTORS"

Whether close relatives of the child (parents, brothers, sisters, dedushyoki, grandmothers) any of listed below diseases suffer?

01. A bronchial asthma, an asthmatic bronchitis,

Pollinosis (an allergy on pollen of plants)........ Yes is not present

02. A food allergy, a medicinal allergy, an urticaria,

Quincke's edema, scrofula..................... Yes is not present

03. A chronic bronchitis, a chronic pneumonia,

Bronchoectatic disease..................... Yes is not present

04. A glomerulonephritis, a hereditary nephritis,

Intersticial nephritis........................ Yes is not present

05. A pyelonephritis, a chronic cystitis, developmental anomalies

(Anomalies) of kidneys and urinary ways...... Yes is not present

06. Is renal-stone illness.................... Yes is not present

07. An epilepsy, syncopes, a migraine................. Yes is not present

08. Diseases of nervous system with statement

On the account and treatment at the neuropathologist............. Yes is not present

09. Mental diseases with statement on

The account and treatment at the psychiatrist..................... Yes is not present
10. A progressing hearing disorder............... Yes is not present

11. An adenoid disease, a chronic sinuitis

(A genyantritis, a frontal sinusitis, etmoidit), a chronic otitis. Yes is not present

12. A chronic gastritis, a chronic duodenitis, hroyonichesky an enteritis, a chronic colitis, ulcerative

Illness, chronic pancreatitis................ Yes is not present

13. Chronic diseases of a liver and zhelchevyvodjashchih ways (a hepatitis, a cirrhosis, a cholecystitis, zhelchekamennaja

Illness)........................................ Yes is not present
14. A psoriasis....................................... Yes is not present
15. An eczema, a neurodermite........................... Yes is not present

16. A myocardial infarction, a stroke (hematencephalon),

Idiopathic hypertensia, hypotension. Yes is not present
17. Diseases of joints (arthritises, polyarthrites). Yes is not present
18. Rheumatic disease, a lupus erythematosus, a scleroderma..... Yes is not present
19. Congenital heart diseases...................... Yes is not present
20. A diabetes............................... Yes is not present
21. Illnesses of a thyroid gland..................... Yes is not present
21. Illnesses of adrenals......................... Yes is not present

22. Oncologic (tumoral) diseases, including

Malignant diseases of blood and brain...... Yes is not present

The block "INSPECTION of the EXPERT IN the REPRODUCTION"

01. Whether were at mother (within 1 year before offensive

Pregnancy) chronic diseases?.......... Yes is not present

02. Whether were at mother (within 1 year before offensive

Pregnancy) gynecologic diseases? Yes is not present

03. If your child has elder sister,

Whether she was ill with gynecologic diseases?. Yes is not present

04. Whether you were ill with gynecologic diseases

Close condanguinity relatives (as from the party

Mothers, and from the father)?................. Yes is not present

05. Whether you applied the hormonal contraceptive

Agents before the given pregnancy

(Within 1 year and more)?...................... Yes is not present

06. Pregnancy the given child proceeded with threat

Abortion?....................................... Yes is not present

07. Whether applied mother during pregnancy

Hormonal preparations (Folliculinum, progesterone,

Turinalum, thyroidine, Prednisolonum, insulin etc.)?. Yes is not present

08. Pregnancy and labours proceeded with complications?. Yes is not present

09. Whether mother during pregnancy was ill (including

Short-term rises in temperature above 37,20?. Yes is not present

10. Labours the given child have occurred before the efflux

37 weeks of pregnancy?......................... Yes is not present

10. Labours the given child have occurred on 42 week

Pregnancy or later?....................... Yes is not present

12. Whether operative measures were applied at sorts

(A Cesarean section, obstetric forcepses,

Vacuum - an ex-traction)?........................... Yes is not present

13. The child was born in tazovom a presentation?........ Yes is not present

14. Whether the diagnosis "a pre-natal infection" yes was made in pregnancy is not present

15. After sorts the child has been enclosed to a breast later two days? Yes is not present

16. Whether there was a duration of sorts less 6ч.,

More than 19 ch.?.................................. Yes is not present

17. How many time was ill with infectious diseases

Your child (including ORZ, a flu)... List them.

18. Whether did to your child of operation apropos appenyoditsita, a peritonitis, a cholecystitis, a stomach trauma, druyogie operative measures in an abdominal cavity?. Yes is not present

19. Whether your child with an adenoid disease with frequent exacerbations (there are frequent anginas) yes is ill is not present

The block "DATA of PRE-MEDICAL INSPECTION of the CHILD"

01. Growth........ Sm

02. Body mass.......... Kg, hundreds grammes

03. A head circle........ Sm

04. A breast circle.......... Sm

05. The top person.......... Sm

06. Length of a foot........ Sm

07. A pulse rate........ A beats/min

08. Frequency of breath.......... In mines

09. Arterial pressure: the systolic..... Mm hg

The diastolic.................................. Mm hg

The FORMALIZED FORM of inspection of the child doctors-experts (parents fill only first three columns)

Surname, name............................................

Date of birth...... D/s, group.............

Otorinolaringolog.......................................

Sulfuric observation

2 - observation of the local doctor

The surgeon the orthopedist)........................................

pansernoe observation

2 - observation of the local doctor

The neuropathologist...........................................

1 it is healthy

2 - observation of the local doctor

The ophthalmologist..............................................

1 - it is healthy

2 - observation of the local doctor

The allergist/lung specialist..................................

1 - it is healthy

2 - observation of the local doctor

The nephrologist....................................................

1 - it is healthy

2 - observation of the local doctor

1 - it is healthy 3

4 - hospitalisation

1 - it is healthy

4 - hospitalisation

3-observation of the neuropathologist

4-SKP (neurologic)

5 - hospitalisation

3 - a dispensary observation

4 - hospitalisation

3 - SKP (allergological)

4 - hospitalisation

3 - i.v. urography

4-SKP (nephrological)

5 - hospitalisation

- dispan -

3 - dis -

The gastroenterologist..........................................

1 - it is healthy

2 - observation of the local doctor

Kardiorevmatolog.......................................

1 - it is healthy

2 - observation of the local doctor

The dermatologist...............................................

1 - it is healthy

2 - observation of the local doctor

The endocrinologist.............................................

1 - it is healthy

2 - observation of the local doctor

3-SKP (gastroenterolo-sky)

4 - hospitalisation

3 - a dispensary observation

4 - hospitalisation

3 - a dispensary observation

4 - hospitalisation

3 - a dispensary observation

4 - hospitalisation

THE CONCLUSION OF THE PEDIATRIST

The diagnosis the basic:......................................

Diagnoses accompanying:................................

Health group: 1 2 3 4 5

Conducting tactics: 0 - medical observation does not require

1 - observation of the local pediatrist

2 - observation of the narrow expert (ov)....... (What)

3 - additional inspection in out-patient conditions (what)

4 - inspection in a hospital.

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Scientific source Homich Michael Mihajlovich. COMPLEX MEDIKO-SOCIAL ESTIMATION of HEALTH of CHILDREN VISITING PRESCHOOL INSTITUTIONS, In VARIOUS REGIONS of the NORTHWEST of Russia. The dissertation on competition of a scientific degree of the candidate of medical sciences. St.-Petersburg - 1996. 1996

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Other medical related information Appendices:

  1. THE TABLE OF CONTENTS
  2. Appendices
  3. the Maintenance
  4. APPENDICES
  5. THE TABLE OF CONTENTS
  6. INTRODUCTION
  7. APPENDICES
  8. the Table of contents
  9. Appendices
  10. INTRODUCTION
  11. THE MAINTENANCE
  12. INTRODUCTION