Page History

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 

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" 

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" 

Do you consume alcohol daily 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Score Logic: 
If "No" then display "0" or If "Yes" then display "1" 

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" 

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" 

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" 

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" 

Shortness of Breath 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Coughing More than 2 weeks * 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Blood in Sputum * 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Fever > 2 weeks * 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Loss of Weight * 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Night Sweats * 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Are you currently taking Anti TB drugs ** 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Anyone in Family Currently Suffering from TB ** 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

History of TB * 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Recurrent of ulceration on Palm or Sole 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Recurrent of tingling on Palm or Sole 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Cloudy or Blurred Vision 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Difficulty in reading 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Pain in eyes lasting for more than weeks 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Redness in eyes for more than weeks 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Difficulty in Hearing 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

History of Fits 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Difficulty in Opening Mouth 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Ulcers in Mouth Not Healed in 2 weeks 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Growth in Mouth Not Healed in 2 weeks 

Spinner 

Is Mandatory 
Choose: 

Any white or red Patch in Mouth Not Healed in 2 weeks 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Pain while chewing 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Any change in Tone of Voice 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Any hypo pigmented patches or discolour lesions with loss of sensation 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Any thickened skin 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Any nodules skin 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Any Patch or Discoloration on Skin 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Recurrent numbness on palm or sole 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Clawing of fingers in hand or feet 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Tingling and numbness in hand / or feet 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Inability to close eye lid

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Difficulty in Holding Objects in hands or Fingers 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Weakness in feet that cause difficulty in walking 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Part B2: Women Only 

Lump in the Breast 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Bleeding after Menopause 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

If option selected is "Yes" then display "Inform ASHA Facilitator." 

Blood Stained Discharge from the Nipple

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Bleeding after intercourse 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Part B3: Elderly Specific 
  

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 " 

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 " 

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 " 

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  
  

Type of Fuel Used for Cooking 

Spinner 

Choose: 
 
Wood, Crop Residue, Gobar Gas, Coal, Kerosene oil, LPG 

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? 

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" 

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" 

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."