Community Based Assessment Checklist (CBAC) Form

NCD Eligible List:
Show all Beneficiary both Male and Female whose age > = 30 years and excluding Pregnant Women.
And this CBAC Form is applicable to screen these Beneficiaries.
This CBAC Form, assessment check should be done yearly once,
Edit is applicable – but once approved by ANM/MO/ CHO, edit is not applicable
Maintain the history of submitted CBAC Form for viewing, year wise

S No	Name of Data Field	Field Type	Value/ Options	Validation/ Logic/ Condition
	CBAC Form
	Date	Calendar Date Picker	Is Mandatory Choose the date from the calendar Format: dd-mm-yyyy Default value Today's Date	Not greater than Today's Date Accept date greater or equal to Date of beneficiary registration should not allow to update in edit or once submitted
	Name	Textbox		Auto fill from Beneficiary details Show: First Name + Last Name Read only
	Age	Textbox		Auto fill from Beneficiary details Read only
	Sex	Textbox		Auto fill from Beneficiary details Read only
	Part A: Risk Assessment
1	What is your Age? (in Age)	Spinner	Is Mandatory Choose: 30 – 39 40 - 49 50 – 59 60 and Above	Auto-populate Age from 'Beneficiary' registration: Score Logic: "Score" is a variable whose Default Score value is "0". If 30 <= Age <= 39 then display "1"If 40 <= Age <= 49 then display "2"If 50 <= Age <= 59 then display "3"If 60 <= Age then display "4"
2	Do you smoke or consume smokeless products such as gutka or khaini	Spinner	Is Mandatory Choose: Never Used to consume in the past sometime now Daily	Score Logic: If option selected "Never" then display "0"If option selected "Used to consume in the past sometime now" then display "1"If option selected = "Daily" then display "2"
3	Do you consume alcohol daily	Spinner	Is Mandatory Choose: Yes No	Score Logic: If "No" then display "0" or If "Yes" then display "1"
4	Measurement of Waist (in cm)	Spinner	Is Mandatory Condition: Show values in the Spinner based on Gender: For Male: Choose: 90 cm or less 91 - 100 cm More than 100 cm For Female: Choose: 80 cm or less 81 - 90 cm More than 90 cm	Score Logic: If "Gender" = "Female" and "Waist length" <= 80 then display "0"If "Gender" = "Female" and 81 <= "Waist length" <= 90 then display "1"If "Gender" = "Female" and "Waist length" > 90 then display "2"If "Gender" = "Male" and "Waist length" <= 90 then display "0"If "Gender" = "Male" and 91 <= "Waist length" <= 100 then display "1"If "Gender" = "Male" and "Waist length" > 100 then display "2"
5	Do you under take any physical activity for minimum of 150 minutes in a week	Spinner	Is Mandatory Choose: At least 150 min in a week Less than 150 min in a week	Score Logic: If "At least 150 min in a week" then display "0" or If "Less than 150 min in a week" then display "1"
6	Do you have any family history (any one of your parents or siblings) of high BP / Diabetes / Heart Disease	Spinner	Is Mandatory Choose: Yes No	Score Logic: If "No" then display "0" or If "Yes" then display "2"
7	Total Score	Label		Total Score Formula: Sum of all above score. Based on the "Total Score" display a message in pop-up as show below: If score is > 4 "Refer to NCD screening day / VHSND/ HWC for NCD screening (Priority)" If score is < = 4 "Refer to NCD screening day / VHSND/ HWC for NCD screening (Less Priority)"
	Part B1: Early Detection Ask if Patient has any of these symptoms
	If "Yes" is selected below then display a pop-up message, "Suspected NCD case, please visit nearest HWC or call 104."
	* If "Yes" is selected for any one of the questions below with "*" then show a pop-up message "Refer to MO and collect the Sputum sample"
	If "Yes" is selected for any one of the questions below with "" then show a pop-up message "Refer to MO or inform ANM/MPW to tracing of all family members"
1	Shortness of Breath	Spinner	Is Mandatory Choose: Yes No
2	Coughing More than 2 weeks *	Spinner	Is Mandatory Choose: Yes No
3	Blood in Sputum *	Spinner	Is Mandatory Choose: Yes No
4	Fever > 2 weeks *	Spinner	Is Mandatory Choose: Yes No
5	Loss of Weight *	Spinner	Is Mandatory Choose: Yes No
6	Night Sweats *	Spinner	Is Mandatory Choose: Yes No
7	Are you currently taking Anti TB drugs **	Spinner	Is Mandatory Choose: Yes No
8	Anyone in Family Currently Suffering from TB **	Spinner	Is Mandatory Choose: Yes No
9	History of TB *	Spinner	Is Mandatory Choose: Yes No
10	Recurrent of ulceration on Palm or Sole	Spinner	Is Mandatory Choose: Yes No
11	Recurrent of tingling on Palm or Sole	Spinner	Is Mandatory Choose: Yes No
12	Cloudy or Blurred Vision	Spinner	Is Mandatory Choose: Yes No
13	Difficulty in reading	Spinner	Is Mandatory Choose: Yes No
14	Pain in eyes lasting for more than weeks	Spinner	Is Mandatory Choose: Yes No
15	Redness in eyes for more than weeks	Spinner	Is Mandatory Choose: Yes No
16	Difficulty in Hearing	Spinner	Is Mandatory Choose: Yes No
17	History of Fits	Spinner	Is Mandatory Choose: Yes No
18	Difficulty in Opening Mouth	Spinner	Is Mandatory Choose: Yes No
19	Ulcers in Mouth Not Healed in 2 weeks	Spinner	Is Mandatory Choose: Yes No
20	Growth in Mouth Not Healed in 2 weeks	Spinner	Is Mandatory Choose:
21	Any white or red Patch in Mouth Not Healed in 2 weeks	Spinner	Is Mandatory Choose: Yes No
22	Pain while chewing	Spinner	Is Mandatory Choose: Yes No
23	Any change in Tone of Voice	Spinner	Is Mandatory Choose: Yes No
24	Any hypo pigmented patches or discolour lesions with loss of sensation	Spinner	Is Mandatory Choose: Yes No
25	Any thickened skin	Spinner	Is Mandatory Choose: Yes No
26	Any nodules skin	Spinner	Is Mandatory Choose: Yes No
27	Any Patch or Discoloration on Skin	Spinner	Is Mandatory Choose: Yes No
28	Recurrent numbness on palm or sole	Spinner	Is Mandatory Choose: Yes No
29	Clawing of fingers in hand or feet	Spinner	Is Mandatory Choose: Yes No
30	Tingling and numbness in hand / or feet	Spinner	Is Mandatory Choose: Yes No
31	Inability to close eye lid	Spinner	Is Mandatory Choose: Yes No
32	Difficulty in Holding Objects in hands or Fingers	Spinner	Is Mandatory Choose: Yes No
33	Weakness in feet that cause difficulty in walking	Spinner	Is Mandatory Choose: Yes No
	Part B2: Women Only
1	Lump in the Breast	Spinner	Is Mandatory Choose: Yes No
2	Bleeding after Menopause	Spinner	Is Mandatory Choose: Yes No	If option selected is "Yes" then display "Inform ASHA Facilitator."
3	Blood Stained Discharge from the Nipple	Spinner	Is Mandatory Choose: Yes No
4	Bleeding after intercourse	Spinner	Is Mandatory Choose: Yes No
	Part B3: Elderly Specific
1	Feeling unsteady while standing or walking	Spinner	Is Mandatory Choose: Yes No	If option selected is "Yes" then display "Send the patient to MOIC of nearest health center for treatment "
2	Suffering from any physical disability that restrict movement	Spinner	Is Mandatory Choose: Yes No	If option selected is "Yes" then display "Send the patient to MOIC of nearest health center for treatment "
3	Needing help from others to perform every day activities such as eating, getting dressed, grooming, bathing, walking, or using the toilets	Spinner	Is Mandatory Choose: Yes No	If option selected is "Yes" then display "Send the patient to MOIC of nearest health center for treatment "
4	Forgetting names of yours, near ones or your own home address	Spinner	Is Mandatory Choose: Yes No	If option selected is "Yes" then display "Send the patient to MOIC of nearest health center for treatment "
	Part C: Risk factor for COPD
1	Type of Fuel Used for Cooking	Spinner	Choose: Wood, Crop Residue, Gobar Gas, Coal, Kerosene oil, LPG
2	Occupational Exposure	Spinner	Choose: Crop residue burning / burning of garbage – leaves/working in industries with smoke, gas and dust exposure such as brick kilns and glass factories etc.
	Part D: PHQ2
	Over the last two weeks bothered by the following problem?
1	Little interest or pleasure in doing things?	Spinner	Choose: Not at all several days more than half the days nearly every day	Score Logic: If option selected is "Not at all" then display "0"If option selected is "several days" then display "1"If option selected is "more than half the days" then display "2"If option selected is "nearly every day" then display "3"
2	Feeling down, depressed or hopeless?	Spinner	Choose: Not at all several days more than half the days nearly every day	Score Logic: If option selected is "Not at all" then display "0"If option selected is "several days" then display "1"If option selected is "more than half the days" then display "2"If option selected is "nearly every day" then display "3"
3	Total Score	Label		Total Score formula: Sum of all the above score If "Total Score" is more than "3" then display pop up message "Refer the person to MOIC for treatment."

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