...
Fields | Validation |
Anthropometric |
|
Weight (Kgs) | - |
Height (cms) | - |
BMI=Weight/(Height/100) ² | Should be auto calculated if height and weight details are entered |
Vitals |
|
Temperature (Degree Fahrenheit) | Give predefined options (Normal range= 97-99 F) a) 97.5 b) 98.5 c) 99.5 d)>= 100 If option d)>= 100 is chosen, show alert "Refer to Health and Wellness Centre" and show such beneficiaries in "Referral" card in Home |
Pulse Rate (beats per minute) | Give predefined options (Normal range= 60-90 BPM) a) less than 60 b) 60-70 c) 70-80 d) More than 90 If "less than 60" or "more than 90" option is chosen, show alert "Refer to Health and Wellness Centre" and show such beneficiaries in "Referral" card in Home |
Systolic Blood Pressure (mm Hg) | Textbox to manually input values. If "less than 90" or "more than 140", show alert "Refer to Health and Wellness Centre" and show such beneficiaries in "Referral" card in Home |
Diastolic blood Pressure (mm Hg) | Textbox to manually input values. If "less than 60" or "more than 90", show alert "Refer to Health and Wellness Centre" and show such beneficiaries in "Referral" card in Home |
Random Blood Sugar | Textbox to manually input values. If "less than 60" or "more than 90", show alert "Refer to Health and Wellness Centre" and show such beneficiaries in "Referral" card in Home |
Referred for
- "Digital Chest X-ray",
- True NAT
- Default option "Digital Chest X-ray" will be selected for everyone except if "age=< 5 years" and "are you pregnant= yes".
- "True NAT" will be the default option for "age=< 5 years" and "are you pregnant= yes".
- Based on the option auto chosen, show beneficiaries in "Digital Chest X-ray", "True NAT" cards in Referral section.
2.2.2.b Suspected TB cases
This section should contain all beneficiaries in the following scenario-
Scenario 1- If not a single symptom is presented in a beneficiary but chest x-ray is positive, show the case here.
Scenario 2- If any symptom or symptoms reported "yes" then show the case here even if chest x-ray/ TrueNAT is negative.
...
Name of data Field
...
Field Type
...
Value/ Options
...
Validation/ Logic/ Condition
...
Date
...
Calendar
Date Picker
...
Mandatory
...
- 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
...
Gender
...
Textbox
...
...
Auto fill from Beneficiary details
Read only
...
Is Digital Chest X-ray conducted
...
...
- Yes
- No
...
- To be enabled if "Referred for" = "Digital Chest X-ray"
...
Digital Chest X-Ray Test Result
...
...
- Positive
- Negative
...
- Enable only if "Digital Chest X-ray conducted"=“Yes”
- If "Positive" is selected, move this case to Confirmed TB cases module.
...
Sputum Test
...
...
- To be enabled in the following conditions-
a) If "Digital Chest X-Ray Test Result"= "Positive"
b) If "History of TB" = "Yes"
c) If "Age=< 5 years"
d) If "Are you pregnant= yes"
...
Is Sputum sample collected?
...
radio button
...
- Yes
- No
...
Is TrueNAT conducted
...
radio button
...
- Yes
- No
...
- To be enabled if "Referred for" = "TrueNAT"
- To be enabled if "Sputum Sample Collected" = "Yes"
...
TrueNAT
...
radio button
...
- Positive
- Negative
...
- Enable only if "TrueNAT conducted"=“Yes”
- Option to edit/ select after submission of the form
- If "Positive" is selected, move this case to Confirmed TB cases module.
...
Is Liquid culture conducted
...
radio button
...
- Yes
- No
...
- To be enabled only if "History of TB" = "Yes" and if "Sputum Sample Collected" = "Yes"
...
Liquid Culture
...
radio button
...
- Positive
- Negative
...
- If "Positive" is selected, move this case to Confirmed TB cases module.
- Option to edit/ select after submission of the form
...
Nikshay ID
...
Textbox
...
...
- Enable if "Yes" is selected for 'Is Sputum sample collected.
- Enable if "Yes" is selected for "Digital Chest X-ray conducted"
- Enable if "Yes" is selected for "NAAT conducted"
...
Capture Geolocation
...
- Capture current location details (latitude, longitude, address)
...
Submit
...
Button
...
...
2.2.2.c Confirmed TB cases
Treatment and follow up of TB confirmed cases.
...
Name of Data Field
...
Field Type
...
Value/ Options
...
Validation/ Logic/ Condition
...
Regimen Type
...
Radio button
...
- DS-TB (6 Months)
- Shorter Regimen (9–12 Months)
- Longer Regimen (18–24 Months)
- BPaL Regimen (6 Months)
- INH Mono (6 Month)
...
Open module 2.2.2.d (TPT- TB Prevention treatment) module if “DS-TB (6 Months)” is selected
Alert to Volunteer to screen all household members/ Contacts if DS-TB case is selected.
...
Treatment Start Date
...
Date picker
...
Mandatory
...
- Should be greater than or equals to TB (Identification and Diagnosis) Visit Date
- Not greater than Today's Date
...
Expected Treatment Completion Date
...
Label
...
Read only
...
Auto calculate this date based on below condition form ‘Treatment Start Date’:
1. If ‘Regimen Type’ is “1”, “4”, “5” then add 6 months
2. If ‘Regimen Type’ is “2”, then, Treatment duration is 9–12 months (show 9–12 range dates)
3. If ‘Regimen Type’ is “3”, then, Treatment duration is 18–24 months (show 18–24 range dates)
...
Follow-up & Adherence
...
Follow up Date
...
Date picker
...
Mandatory
...
- Greater than or equal to Treatment Start Date or greater than Last Follow up Date
- Minimum date is Treatment Start Date
- Accept date greater than Last Follow up Date
- Allow 1 Follow up visit in a month (i.e. monthly 1 Follow up)
- Not greater than Today's Date
...
Monthly follow up done
...
Label
...
Month-1 to Month-24
...
- Should be incremental based on monthly Follow up
...
Adherence to Medicines
...
Radio button
...
- Regular
- Irregular
...
...
Any discomfort
...
Radio button
...
- Yes
- No
...
...
Treatment Completion
...
Did the patient complete the full course of treatment?
...
Radio button
...
- Yes
- No
...
Enable these below filed based on below conditions:
1. If ‘Regimen Type’ is “1”, “4”, “5” then enable after 5 Monthly follow up visits
2. If ‘Regimen Type’ is “2”, then enable after 9 Monthly follow up visits
3. If ‘Regimen Type’ is “3”, then enable after 18 Monthly follow up visits
...
Actual Treatment Completion Date
...
Date picker
...
...
- Enable this filed if “Yes” is selected above
- Greater than Last Follow up Date
...
TB Treatment outcomes
...
Dropdown
...
- Cured
- Failed
- Lost to Follow-up (LFU)
- Death
...
If "Death" is selected, update 'Beneficiary Status' = "Death" in the Beneficiary record, with “Date of Death”, "Place of Death" and "Reason for Death” in the next fields.
...
Date of Death
...
Date picker
...
...
- Enable only if "TB Treatment outcomes" = “Death” and it is Mandatory
- By default, date is null
- Not greater than Today’s Date
- Greater than or equal to Treatment Start Date or greater than Last Follow up Date
...
Place of Death
...
Dropdown
...
- Home
- Subcenter
- PHC
- CHC
- District Hospital
- Medical College Hospital
- Private Hospital
- Other Place
...
Enable only if "TB Treatment outcomes" = “Death”
...
Reason for Death
...
Label
Read only
...
Tuberculosis
...
Enable only if "TB Treatment outcomes" = “Death”
...
Reason for non completion of treatment
...
Textbox
...
...
Enable this field if “No” selected for “Did the patient complete full treatment?”
...
Capture Geolocation
...
- Capture current location details (latitude, longitude, address)
...
Submit
...
button
...
...
...
Follow up visit history
...
Table
...
...
Maintain a Follow up visit history of Visit
Referred for | Auto selection |
|
|
2.2.2.b Suspected TB cases
This section should contain all beneficiaries in the following scenario-
Scenario 1- If not a single symptom is presented in a beneficiary but chest x-ray is positive, show the case here.
Scenario 2- If any symptom or symptoms reported "yes" then show the case here even if chest x-ray/ TrueNAT is negative.
Name of data Field | Field Type | Value/ Options | Validation/ Logic/ Condition |
Date | Calendar | Mandatory |
|
Name | Textbox |
| Auto fill from Beneficiary details |
Age | Textbox |
| Auto fill from Beneficiary details |
Gender | Textbox |
| Auto fill from Beneficiary details |
Is Digital Chest X-ray conducted |
|
|
|
Digital Chest X-Ray Test Result |
|
|
|
Sputum Test |
|
a) If "Digital Chest X-Ray Test Result"= "Positive" b) If "History of TB" = "Yes" c) If "Age=< 5 years" d) If "Are you pregnant= yes" | |
Is Sputum sample collected? | radio button |
| |
Is TrueNAT conducted | radio button |
|
|
TrueNAT | radio button |
|
|
Is Liquid culture conducted | radio button |
|
|
Liquid Culture | radio button |
|
|
Nikshay ID | Textbox |
|
|
Capture Geolocation |
| ||
Submit | Button |
|
|
2.2.2.c Confirmed TB cases
Treatment and follow up of TB confirmed cases.
Name of Data Field | Field Type | Value/ Options | Validation/ Logic/ Condition |
Regimen Type | Radio button |
| Open module 2.2.2.d (TPT- TB Prevention treatment) module if “DS-TB (6 Months)” is selected Alert to Volunteer to screen all household members/ Contacts if DS-TB case is selected.
|
Treatment Start Date | Date picker
| Mandatory |
|
Expected Treatment Completion Date | Label | Read only | Auto calculate this date based on below condition form ‘Treatment Start Date’: 1. If ‘Regimen Type’ is “1”, “4”, “5” then add 6 months 2. If ‘Regimen Type’ is “2”, then, Treatment duration is 9–12 months (show 9–12 range dates) 3. If ‘Regimen Type’ is “3”, then, Treatment duration is 18–24 months (show 18–24 range dates) |
Follow-up & Adherence | |||
Follow up Date | Date picker
| Mandatory |
|
Monthly follow up done | Label | Month-1 to Month-24 |
|
Adherence to Medicines | Radio button |
|
|
Any discomfort | Radio button |
|
|
Treatment Completion | |||
Did the patient complete the full course of treatment? | Radio button |
| Enable these below filed based on below conditions: 1. If ‘Regimen Type’ is “1”, “4”, “5” then enable after 5 Monthly follow up visits 2. If ‘Regimen Type’ is “2”, then enable after 9 Monthly follow up visits 3. If ‘Regimen Type’ is “3”, then enable after 18 Monthly follow up visits |
Actual Treatment Completion Date | Date picker |
|
|
TB Treatment outcomes | Dropdown |
| If "Death" is selected, update 'Beneficiary Status' = "Death" in the Beneficiary record, with “Date of Death”, "Place of Death" and "Reason for Death” in the next fields. |
Date of Death | Date picker |
|
|
Place of Death | Dropdown |
| Enable only if "TB Treatment outcomes" = “Death” |
Reason for Death | Label Read only | Tuberculosis | Enable only if "TB Treatment outcomes" = “Death” |
Reason for non completion of treatment | Textbox |
| Enable this field if “No” selected for “Did the patient complete full treatment?” |
Capture Geolocation |
| ||
Submit | button |
|
|
Follow up visit history | Table |
| Maintain a Follow up visit history of Visit |
2.2.2.d Tuberculosis Preventive Treatment
Tuberculosis Preventive Treatment (TPT)
- TPT is the preventive treatment given to close contacts of confirmed Drug-Sensitive TB (DS-TB) cases who are at high risk of developing active TB.
- If a contact tests positive for active TB at any step (X-Ray or Sputum positive), the system must immediately redirect the volunteer to create a new TB Suspected Case record for that contact — bypassing the TPT flow.
- This module should open when in Confirmed TB case module, “Regimen type” = “DS-TB (6 months)”
- Make this module editable as after referral of the contact for diagnostic tests, volunteer needs to enter further details once the tests are done.
Household Contact Line listing Screen-
Name of data field | Field Type | Value/ Options | Validation/ logic/ condition |
Name of the contact | Text Box |
| |
Age of the contact |
| ||
Gender | Dropdown |
|
|
Mobile Number | Number |
| |
TPT (TB Preventive Treatment) Screening Status |
|
|
|
Referral Facility for screening |
|
|
|
Screening done at the referral facility |
|
|
|
Is it confirmed TB case |
|
|
|
Are you advised to take (TPT) |
|
|
|
TPT initiated |
|
|
|
TPT start date | Date picker | =<Today’s date |
|
Treatment duration of TPT |
|
|
|
Expected completion date | date |
|
|
Follow up visit number | Numeric |
|
|
Follow up visit date | Date picker | =<Today’s date |
|
TPT completion status |
|
|
|
Other | Free text | ||
Date of completion | Date picker | =<Today’s date |
|
Date of death | Date picker |
|
|
Cause of death | Free text |
|
|
Capture Geolocation |
| ||
Submit |
|
|
|
2.2.3 Module- Non Communicable Disease (NCD) Screening
Should be enabled for beneficiaries aged 30 years and above
Optional Module.
Name of data field | Field type | Options/ values | Validation/ Logic |
Hypertension Screening | |||
Have you ever been diagnosed with high blood pressure? | · Yes · No · Don’t Know | · Single selection allowed · Optional | |
Are you currently taking medication for blood pressure? | · Yes · No · Stopped recently | · To be enabled if “Have you ever been diagnosed with high blood pressure” = “Yes” · Optional | |
Does anyone in your family have high blood pressure | · Yes · No · Don’t Know | · Single selection allowed · Optional | |
Have you experienced any of the following symptom/ symptoms | · Dizziness · Swollen legs · Frequent headaches · None | · Optional · Multiple selection possible · 'None' selection should deselect all others | |
Systolic BP | Number- | Values to be captured in (mmHg) | · Optional · If "less than 90" or "more than 140", show alert "Refer to Health and Wellness Centre" and show such beneficiaries in "Referral" card in Home |
Diastolic BP | Number | Values to be captured in (mmHg) | · Optional · If "less than 60" or "more than 90", show alert "Refer to Health and Wellness Centre" and show such beneficiaries in "Referral" card in Home |
Diabetes Screening | |||
Have you been diagnosed with diabetes or pre-diabetes? | · Yes · No · Don’t Know | · Single selection allowed · Optional | |
Are you currently on medication or insulin for diabetes? | · Yes · No · Stopped recently | · To be enabled if “Have you been diagnosed with diabetes or pre-diabetes?” = “Yes” · Optional | |
Have you experienced any of the following symptom/ symptoms in the past 3 months | · Excessive thirst · Frequent urination · Unexplained weight loss · Blurred vision · Tingling/numbness in feet · Fatigue · Slow-healing wounds · None | · Optional · Multiple selection possible · 'None' selection should deselect all others | |
Random Blood Sugar | Number | Values to be captured in (mg/dl) | · Optional · If >= 100 mg/dl then show alert "Refer to Health and Wellness Centre" and show such beneficiaries in "Referral" card in Home |
2.2.2.d Tuberculosis Preventive Treatment
Tuberculosis Preventive Treatment (TPT)
- TPT is the preventive treatment given to close contacts of confirmed Drug-Sensitive TB (DS-TB) cases who are at high risk of developing active TB.
- If a contact tests positive for active TB at any step (X-Ray or Sputum positive), the system must immediately redirect the volunteer to create a new TB Suspected Case record for that contact — bypassing the TPT flow.
- This module should open when in Confirmed TB case module, “Regimen type” = “DS-TB (6 months)”
- Make this module editable as after referral of the contact for diagnostic tests, volunteer needs to enter further details once the tests are done.
Household Contact Line listing Screen-
...
Name of data field
...
Field Type
...
Value/ Options
...
Validation/ logic/ condition
...
Name of the contact
...
Text Box
...
...
Age of the contact
...
...
Gender
...
Dropdown
...
- Male
- Female
- Transgender
- Prefer not to say
...
- Mandatory
- Speech to text feature
...
Mobile Number
...
Number
...
- Optional
- Speech to text feature
...
TPT (TB Preventive Treatment) Screening Status
...
...
- Not Started
- Pending
- Completed
...
- Mandatory
- Single selection allowed
- Default option is Pending
...
Referral Facility for screening
...
...
- HWC
- PHC
- CHC
- District Hospital
...
- Mandatory.
- Single selection allowed
- From here it can directly go to submit option as the contact first needs to get tested and confirmed if he/ she have to take TPT.
...
Screening done at the referral facility
...
...
- Yes
- No
...
- Mandatory
...
Is it confirmed TB case
...
...
- Yes
- No
...
- If yes, move the card to confirmed TB list.
- If no, continue ahead.
...
Are you advised to take (TPT)
...
...
- Yes
- No
...
- If yes, continue with the next field.
- If no, then directly go to submit option.
...
TPT initiated
...
...
- Yes
- No
...
- Mandatory
- Enable next fields if selected Yes.
...
TPT start date
...
Date picker
...
=<Today’s date
...
- Mandatory if enabled
- Cannot be future date
- Cannot be before the date of screening
...
Treatment duration of TPT
...
...
- 1 Month
- 3 month
- 6 month
...
...
Expected completion date
...
date
...
- Auto calculated
...
- Auto calculated= TPT start date + regimen duration
- Non editable
...
Follow up visit number
...
Numeric
...
- Auto increment (1-6)
...
- Non editable
- Automatic calculation by system
...
Follow up visit date
...
Date picker
...
=<Today’s date
...
- Mandatory if enabled
- Cannot be future date
- Cannot be before the TPT start date
...
TPT completion status
...
...
- Completed
- Incomplete
- Lost to follow up
- Developed active TB during TPT
- Died during TPT
- other
...
- Mandatory
- If selected “Completed” then enable date of completion field
- If selected “developed active TB during TPT” then redirect volunteer to create new case record for active TB and close the TPT case.
- If selected “died during TPT” then enable date of death field and cause of death field
...
Other
...
Free text
...
...
...
Date of completion
...
Date picker
...
=<Today’s date
...
- Mandatory if enabled
- Cannot be future date
...
Date of death
...
Date picker
...
...
- To be enabled if “TPT completion status” = Died during TPT
- Mandatory if enabled
...
Cause of death
...
Free text
...
...
- To be enabled if “TPT completion status” = Died during TPT
- Mandatory if enabled
...
Capture Geolocation
...
- Capture current location details (latitude, longitude, address)
...
Submit
...
...
...
2.2.3 Module- Non Communicable Disease (NCD) Screening
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, 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)
...
radio button
...
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
...
radio button
...
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
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
Score Logic:
If "No" then display "0" or If "Yes" then display "1"
...
Measurement of Waist (in cm)
...
radio button
...
Is Mandatory
Condition:
Show values in the radio button 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
...
radio button
...
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
...
radio button
...
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
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Coughing More than 2 weeks *
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Blood in Sputum *
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Fever > 2 weeks *
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Loss of Weight *
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Night Sweats *
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Are you currently taking Anti TB drugs **
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Anyone in Family Currently Suffering from TB **
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
History of TB *
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Recurrent of ulceration on Palm or Sole
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Recurrent of tingling on Palm or Sole
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Cloudy or Blurred Vision
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Difficulty in reading
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Pain in eyes lasting for more than weeks
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Redness in eyes for more than weeks
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Difficulty in Hearing
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
History of Fits
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Difficulty in Opening Mouth
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Ulcers in Mouth Not Healed in 2 weeks
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Growth in Mouth Not Healed in 2 weeks
...
radio button
...
Is Mandatory
Choose:
...
...
Any white or red Patch in Mouth Not Healed in 2 weeks
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Pain while chewing
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Any change in Tone of Voice
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Any hypo pigmented patches or discolour lesions with loss of sensation
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Any thickened skin
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Any nodules skin
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Any Patch or Discoloration on Skin
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Recurrent numbness on palm or sole
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Clawing of fingers in hand or feet
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Tingling and numbness in hand / or feet
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Inability to close eye lid
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Difficulty in Holding Objects in hands or Fingers
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Weakness in feet that cause difficulty in walking
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Part B2: Women Only
...
...
...
...
Lump in the Breast
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Bleeding after Menopause
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
If option selected is "Yes" then display "Inform ASHA Facilitator."
...
Blood Stained Discharge from the Nipple
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Bleeding after intercourse
...
radio button
...
Is Mandatory
Choose:
- Yes
- No
...
...
Part B3: Elderly Specific
...
...
...
...
Feeling unsteady while standing or walking
...
radio button
...
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
...
radio button
...
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
...
radio button
...
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
...
radio button
...
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
...
radio button
...
Choose:
Wood, Crop Residue, Gobar Gas, Coal, Kerosene oil, LPG
...
...
Occupational Exposure
...
radio button
...
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?
...
radio button
...
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?
...
radio button
...
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."
...
Capture Geolocation
...
- Capture current location details (latitude, longitude, address)
...
Submit
...
...
...
2.2.4 Module - Referrals
This module should contain the list of names/ cases referred to health facilities.
...
- Time Period- based on "today and previous months" This filter should show all the data cards in the dashboard pertaining to the time period selected. (eg: today, Jan, Feb etc)
- Village Name- Dropdown options to be populated with names of village/ hamlets
...
Field Name | Field Type | Options | Validation |
Filter/ Selection option | Dropdown | The Dropdown Values are
| If this filter is selected, then show all the values of the dashboard indicators pertaining to the time period selected. |
Filter/ Selection option | Dropdown | Village/ Hamlet names to be put here | If this filter is selected, then show all the values of the dashboard indicators pertaining to the particular village selected. |
Total TB screenings | Card must be yellow in colour | It must auto populate based on the filter selected. | |
Total TB suspected cases | Card must be yellow in colour | It must auto populate based on the filter selected. | |
Total TB confirmed cases | Card must be yellow in colour | It must auto populate based on the filter selected. | |
NIKSHAY IDs | Card must be yellow in colour | Total number of NIKSHAY IDs made in the selected time period or Village | |
ABHA IDs | Card must be yellow in colour | Total number of ABHA IDs made in the selected time period or Village |
...