Page History

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Field Name	Field Type	Value/ Options	Validation/ Logic
Date of registration			Should be auto selected and updated when the volunteer logs in the application to do the screening.
Photo	Camera	Optional	Should have face detection/ Facial recognition Camera should identify & capture human face but not any objects Show an Alert if Photo is not captured, just as reminder but Not Mandatory Alert: "Do you like to Take Photo", Yes or No If "Yes", open Camera; If "No", go to next
Beneficiary Status		Alive Dead
First Name	Text		Mandatory Speech to text feature
Last Name			Optional
Age	Number (Years)		Mandatory If DOB unknown, approximate age allowed
Date of Birth	Date Picker		Populate Age automatically if entered
Gender	Dropdown	Male Female Transgender Prefer not to say	Mandatory Speech to text feature
Mobile Number	Number		Optional Speech to text feature
Village/ Hamlet	dropdown
Marital Status	Spinner	Unmarried Married Divorced Separated Widow Widower	Not Applicable for Newborn/ Child/ Adolescent (Age 0 to less than 18 Years) Mandatory and editable Show this field once above Gender is selected Based on the 'Gender' values in this dropdown list should change as follows: In case of 'Gender' = "Female" show "Widow" and hide "Widower" In case of 'Gender' = "Male" show "Widower" and hide "Widow" Above in field 'Relationship with head of family' is selected as "Husband" or "Wife" then auto select "Married"
Husband's/ Wife's Name	Textbox	Is Conditionally Mandatory	Input method: Speech to Text feature Hide this field in case of 'Marital Status' = "Unmarried" Optional (Not Mandatory) in case of 'Marital Status' = "Divorced" Based on the Gender show label name as: 'Husband's' or 'Wife's Name' Accept alphabets only Character limit 50 All letter should be in caps
Father's Name	Textbox		Input method: Speech to Text feature Optional (Not Mandatory) in case of 'Gender' = "Female" and 'Marital Status' = "Married" Accept alphabets only Character limit 50 All letter should be in caps
Mother's Name	Textbox		Input method: Speech to Text feature Optional (Not Mandatory) in case of 'Gender' = "Female" and 'Marital Status' = "Married" Accept alphabets only Character limit 50 All letter should be in caps
Community	Spinner	General SC ST OBC OC Not Given	Mandatory But it should be editable
Religion	Spinner	Hindu Muslim ChristenChristian Sikhism Buddhism Jainism Parsi Other Not disclosed	Mandatory But it should be editable
Economic Status	Spinner	Is Mandatory Choose: APL BPL Don't know
Type of Residential area	Spinner	Choose: Rural Urban Tribal Tea Garden Other
Other Type of Residential area	Textbox		Enable if other is selected above Is Mandatory if other is selected above Allow Alphanumeric Character and special Characters Character limit 100
Occupation			Default value is unknown
Cancel	Button		If cancel is selected, a pop up message "Are you Sure?" with options "Yes" and "No" will come. If selected "yes" navigate back to home page If selected "no" then do not erase the patient health data and let the page remain open so it can be submitted by volunteer as sometime by mistake cancel button is clicked.
Submit			On clicking this, it must display the Pop up msg "Patient Registered successfully" This must store the data of the patient and display the required fields over the Beneficiary card Ensure that data should go to server.

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Note: The common questions in CBAC Part B1 and TB screening form, if either of the form is filled and submitted first, then responses in the other form should be automatically selected.

Community Based Assessment Checklist (CBAC) Form

NCD (Non-Communicable Diseases) 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

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."

2.2.4 Module - Referrals

2.3 Home Page- Dashboard

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2.2.4 Module - Referrals

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