Photo of the beneficiary

Name

Beneficiary ID

Age (years)/ Gender

Phone Number

Village Name

ABHA ID (clickable button to initiate ABHA generation)

Condition

Sub Category

Reason for Visit

• All Gender
• All age Group

Care for common ENT problems

• Ear (E)
• Nose (N)
• Throat (T)

• All Gender
• All age Group

Care for Common Ophthalmic problems

• Screening
• Symptomatic
• First aid for eye injury, trauma

• All Gender
• All age Group

Basic Oral health care

• Dental

• All Gender
• All age Group (except less than 11 years of age- only referral)

Basic management of Mental health ailments.

• Emotional or behavioural concerns
• Substance use related concerns
• Thoughts of self-harm or suicide
• Memory loss or confusion
• Seizures / fits or loss of consciousness

• Age Greater than 60 Male/Female

Elderly & Palliative Health Care

• General geriatric complaints
• Functional decline or dependency
• Persistent pain
• Distressing symptoms
• Caregiver support / counselling

• Age Greater than 30 Male/Female

Screening, Prevention, Control and Management of Non-Communicable Diseases (NCD)

• All Gender
• All age Group

Management of Communicable Diseases including National Health Programs

Name of Data Field

Field Type

Value/ Options

Validation/ Logic/ Condition

Date of Visit

Calendar Date Picker

• Is Mandatory
• Choose the date from the calendar
• Format: dd-mm-yyyy

• Not greater than Today's Date
• Accept date greater or equal to Date of EC registration
• should not allow to update in edit or once submitted
• Monthly only 1 Visit is allowed

Financial Year

Auto-populated

• Default Null

• Depends on Date of visit
• visit date based Financial Year

Visit Month

Label

Select Month Default value is current Month

• Auto select current Month
• And should be editable

LMP Date

Calendar Date Picker

• Not greater than Today's Date
• Accept date backing up to 6 Months

Is Pregnancy Test done?

Radio Button

Default Value null

• Yes
• No

• If "Is Pregnancy Test done?" = "Yes", then the "Pregnancy Test Result" field should be enabled and made mandatory.
• If "Is Pregnancy Test done?" = "No", then hide the field 'Is the Woman Pregnant?' and
• If "Is Pregnancy Test done?" = "No" OR "Don't Know", then enable "Are you using any Family Planning Method?" field below.

Pregnancy Test Result

Radio Group

Choose:

• Negative
• Positive Default value Null

• Default Value null
• If 'Pregnancy Test Result' = "Positive" then the field 'Is the Woman Pregnant?' set to "Yes" and then move the EC to 'Pregnant Woman' section for PW Registration.
• Then, 'Status of Woman' should change to "Pregnant Woman".
• If 'Pregnancy Test Result' = "Negative", then 'Is the Woman Pregnant?' set to "No" and hide this field and
• then enable "Are you using any Family Planning Method?" field below.

Is the Woman pregnant?

Radio Group

• Default Value null
• Yes
• No

• If "No", enable "Are you using any Family Planning Method?" field below.
• If "Yes", then move the EC to 'Pregnant Woman' section for PW Registration
• Then, Status of Woman should change to "Pregnant Woman"

Are you using any Family Planning Method?
or
Do you want to use any Planning Method?

Radio Group

Choose: Yes / No

• Default Value null
• if "Yes" is chosen, enable "Method of Contraception" field below

Method of Contraception

Spinner

• Self
• ANTRA Injection
• Copper T (IUCD)
• Condom
• Mala N
• Chaya
• ECP
• MALE STERILIZATION
• FEMALE STERILIZATION
• MiniLap
• Any Other Method

• 'No of Children' = "0", then hide these three items in the dropdown list "FEMALE STERILIZATION", "MALE STERILIZATION" and "Minilap"
• Default Value null
• Open "Any Other Method" Text Box on selection of "Any Other Method" option and is mandatory.
• If "ANTRA Injection" is selected, then enable three fields below 'ANTRA Injection' "Dose", "Date of Injection" and "Due date of next Injection"
• If 'Method of Contraception' is "FEMALE STERILIZATION" or "MALE STERILIZATION" or "Minilap" is selected, then update 'Status of Women' to "Permanently Sterilised" and move Women record out of EC and ECT section.
• On selecting "ANTRA Injection" or any "Sterilization Method" show alert box: Show an Alert! respectively as below: "Please upload MCA Card photo to claim your Incentive"
  "Please upload Discharge summary photo to claim your Incentive"

Any Other Method

Edit Text Box

• Default Value Null

• Accept alphabets only
• Character limit 50

Date of Sterilisation

Calendar

Conditionally Mandatory

• Enable only If 'Method of Contraception' is "FEMALE STERILIZATION" or "MALE STERILIZATION" or "Minilap" is selected, and is Mandatory
• Not greater than Today's Date
• Accept date back up to 2 months
  Show an Alert! Please upload "Discharge Summary" photo copy to claim your Incentive.

ANTRA Injection - Dose

Spinner

Conditionally Mandatory
Select options:

• 1st Dose
• 2nd Dose
• 3rd Dose
• 4th Dose
• 5th Dose to 10th Dose

• Enable only "ANTRA Injection" is selected above
• for first time show "Dose-1" and next "Dose-2" and next as follows for continuation of dose
• Auto select the applicable Dose
• If gap is more than 120 days between any 2 doses then restart form "Dose-1"; i.e. beneficiary has to start again from 1st dose

Date of ANTRA Injection

Calendar

Conditionally Mandatory

• Format: dd-mm-yyyy

• Enable only "ANTRA Injection" is selected above
• Not greater than Today's Date
• Accept date back up to 2 months for "Dose-1" and for next Dose validate form 1st dose
  Show an Alert! Please upload "MPA Card" photo copy to claim your Incentive.

Due date of next Injection

Label

• Enable only "ANTRA Injection" is selected above
• The difference between two doses should not be less than 75 days and more than 120 days.
• If gap is more than 120 days between any 2 doses then restart form "Dose-1"; i.e. beneficiary has to start again from 1st dose
• Auto-calculate next due date & grace period
• Next due date & grace period calculation formula: Next due date = Date of ANTRA Injection + 76 Days up to Date of ANTRA Injection + 120 Days

MPA Card
Applicable for ANTRA Injection

File upload

Enable only if 'Method of Contraception' = "ANTRA Injection" is selected.

MPA Card

View Image

Option to view images

Enable only if 'Method of Contraception' = "ANTRA Injection" is selected.

Discharge Summary
Applicable for Sterilization Method

File upload

Option to upload 2 images

• Enable only If 'Method of Contraception' is "FEMALE STERILIZATION" or "MALE STERILIZATION" or "Minilap" is selected

Discharge Summary

View Image

Option to view images

• Enable only If 'Method of Contraception' is "FEMALE STERILIZATION" or "MALE STERILIZATION" or "Minilap" is selected

Submit

Button

• If "ANTRA Injection" dose is selected and submitted, then in line listing on the Beneficiary card Indicate with "ANTRA" label and Next due date.
• If 'Method of Contraception' is "FEMALE STERILIZATION" or "MALE STERILIZATION" or "Minilap" is selected, then update 'Status of Women' to "Permanently Sterilised" and move Women record out of EC and ECT section.
• 'Is the Woman pregnant?' is "Yes", then update 'Status of Woman' to "Pregnant Woman" and navigate to 'Pregnant Woman' registration section,
• else continue in EC Tracking

ANTRA Injection Details

Table

• Applicable only for Beneficiaries "ANTRA Injection" is taken
• Show under "view" visit details screen
• Show following details in the tabular format: Dose, Date, Next due date for every Injection dose

Data Field

Field Type

Value/Options

Validation / Logic

Date of ANC Visit

Date

dd-mm-yyyy
(to be chosen from calendar)

• Mandatory
• Cannot exceed current date
• Default date should be null
• Format dd-mm-yyyy
• Accept Date after 5 weeks from LMP Date
• Date less than 4 weeks from Last ANC Date must not be allowed.
• Accept date greater than Last ANC Date.
• And not greater than Date "42 weeks of Pregnancy"; i.e. maximum Date is 42 weeks from LMP Date

ANC Visit Number

Auto

• 1^st visit
• 2^nd visit
• 3^rd visit
• 4^th visit

• Mandatory
• Auto-populated based on the time when data entry happens as it should calculate the number of visit based on prior history but it should be editable.
• Default Value is auto select based on below conditions
• Display ANC 1, if "ANC Date" is within 12 weeks from LMP Date.
• Display ANC 2, if "ANC Date" is between 14- 26 weeks from LMP Date.
• Display ANC 3, if "ANC Date" is between 28-36 weeks from LMP Date.
• Display ANC 4, if "ANC Date" is between 36 weeks up to EDD from LMP Date.

Gestational Age (Weeks)

Auto-calculated

Display as "X weeks Y days"

• Auto-calculated and mandatory
• Current date minus LMP date

Weight

Number

Number- kg

• Mandatory
• Accept numbers only
• Values from 30 to 200
• Character limit 3

BP(Systolic)

Number

Numeric- mmHg

• Mandatory
• Accept numeric (integer) value only
• Values from 50 to 300
• Default value 0
• If value is < 90 or ≥140 mmHg → show alert for HRP (High Risk Pregnancy)

BP(Diastolic)

Number

Numeric- mmHg

• Mandatory
• Accept numeric (integer) value only
• Values from 30 to 200
• Default Value 0
• If value is < 60 or >= 90 mm Hg → show alert for HRP (High Risk Pregnancy)

Blood Sugar (Fasting)

Number

Numeric- mg/dl

• Mandatory
• Range 40-400 mg/dL
• Show alert if >95mg/dl

Urine Sugar

Dropdown

• Negative
• Trace
• +
• ++
• +++

• Mandatory
• If selected negative or trace, move to the next question without any alert.
• + or more → show alert for HRP (High Risk Pregnancy)

Fundal Height

Custom Number Picker

• Must accept numeric (integer) value only
• Character limit 2 Default value null

• Disable field up to 12 Weeks of Pregnancy.
• Accept numeric (integer) value only
• Accept values up to 2 digits
• Do not allow decimals

Fetal Heart Rate (FHR)

Number

BPM

• Accept decimal numbers only, up to one decimal place
• Accept values up to 3 digits
• Allow range minimum 40.0 to maximum 200.0 bpm
• If FHR<110 bpm→ show alert for bradycardia
• If FHR>160 bpm→ show alert for tachycardia
• If <110 or >160 → show alert for HRP (High Risk Pregnancy)

Urine Albumin

Dropdown

• Negative
• Trace
• +
• ++
• +++

• Mandatory
• If selected negative or trace, move to the next question without any alert.
• + or more → show alert for HRP (High Risk Pregnancy)

Hb Level

Number

g/dL

• Mandatory
• If <7 → Severe Anemia → show alert for HRP (High Risk Pregnancy)

Date of TD dose 1

Date Picker

• dd-mm-yyyy
• Choose the date from the calendar

• TD= Tetanus Diphtheria
• Format dd-mm-yyyy
• Accept date between 5 weeks from LMP Date up to 36 Week of LMP
• Not greater than Today's Date
• Default Value: to be null if no data is entered.
• Disable this data field if
  
  "TD dose 2" or '"Date of TT Booster Dose" is entered in the Last ANC Visit.

TD dose 2 given

Date Picker

• dd-mm-yyyy
• Choose the date from the calendar

• Enable only if TD dose 1 date is documented
• Accept date after 4 weeks from TD dose 1 given to date up to 36 weeks of LMP
• Enable this data field if "Date of TD 1^st Dose" is entered in the Last ANC Visit.
• If "TD 2^nd Dose" is given in the Last ANC Visit, then display a message "All TD doses are given"
• Not greater than Today's Date
• Disable this data field if "Date of TD Booster Dose" is entered in the Last ANC Visit.
• If "TD 2^nd Dose" is given in the Last ANC Visit, then message as "All TD doses have been given" must appear alongside the data field.

TT booster dose given

Date Picker

• dd-mm-yyyy
• Choose the date from the calendar
  
  
  

• Mandatory
• Enable only if TT dose 2 given date is documented
• Accept date between 5 weeks from LMP Date up to up to 36 Week of LMP
• Not greater than Today's Date
• Default Value: to be null if no data is entered.
• Disable this data field if "Date of TD 1^st Dose" is entered in the Last ANC Visit.
• If "Date of TD Booster Dose" is entered in the Last ANC Visit, then message as "All TD doses have been given" must appear alongside the data field.

No. of IFA tabs given

Custom Number Picker

• Must accept numeric (integer) value only
• Default Value 0

• Disable field up to 12 Weeks of Pregnancy.
• Default Value: to be null if no data is entered
• Accept value up to 400

Calcium Given

Custom Number Picker

• Must accept numeric (integer) value only
• Default Value 0

• Disable field up to 14 Weeks of Pregnancy.
• Default Value: to be null if no data is entered
• Accept value up to 400

Danger Signs

Multi-select

• Vaginal Bleeding
• Swelling of hands, feet or face
• Severe Headache
• Blurred Vision
• Convulsions/ seizures
• Severe abdominal pain
• Fever > 38°C
• Painful urination/ Burning
• Reduced fetal movement
• Vaginal fluid leakage
• Persistent vomiting
• Breathlessness/ chest pain

• Mandatory
• Multiple selection should be possible
• On any selection→ show alert for HRP (High Risk Pregnancy)

Counselling Provided

Dropdown

• Yes
• No

• If "Yes"→ enable next question

Which counselling was provided?

• Nutrition
• Birth Preparedness and Complication readiness
• Identification of danger signs
• Medication compliance (IFA/ Calcium/ other medications)
• Immunization
• Hygiene and Infection Prevention

• Mandatory if enabled
• Multiselect
• Should be enabled if above question is "Yes"
  
  
  

Next ANC Visit Date

Calendar

• Choose the date from the calendar
• Format: dd-mm-yyyy

• Greater than Today's Date
• Should be < = EDD

Next Button

• Proceed to vital screen and prescription.

Data Field

Field Type

Value/Options

Validation / Logic

Name of the woman

Auto-populated

From pregnancy registration

• Auto populate
• Display only (non-editable)
• Should show: Name, Age, Case ID
• Should link to full ANC history

Date of Delivery

Date picker

dd/mm/yyyy

• Mandatory
• Cannot be future date
• Must be ≥ EDD minus 4 weeks (premature) and ≤ EDD plus 2 weeks (post-term)
• If >14 days from EDD → Show alert: "Post-term delivery"
• If <37 weeks gestation → Auto-flag as "Preterm delivery"

Time of Delivery

Time picker

HH:MM (12-hour format)

Gestational Age at Delivery

Auto-calculated

Weeks + Days (e.g., 38w 5d)

• Auto-calculated from LMP/EDD
• Non editable
• Display only
• Based on the classification below show alert-
  
  
  
• <28 weeks: Extremely Preterm
• 28-32 weeks: Very Preterm
• 32-37 weeks: Moderate to Late Preterm
• 37-42 weeks: Term
• >42 weeks: Post-term

Place of Delivery

Dropdown (Single select)

• Sub-Centre
• Primary Health Centre (PHC)
• Community Health Centre (CHC)
• District Hospital (DH)
• Medical College Hospital
• Referral/Tertiary Hospital
• Private Hospital
• Home delivery
• On the way to facility

• Mandatory
• If "Home delivery" → Show alert: "Home delivery occurred. Provide counselling on risks. Ensure immediate PNC visit."
• If "Private Hospital" → Enable field for hospital name
• If "Home delivery" or "On the way" → Show alert for urgent PNC home visit within 24 hours

If Private Hospital, specify name

Text field

text

• Enable only if place of delivery = "Private Hospital"
• Optional
• Free text (100 char limit) -

Delivery conducted by

Dropdown

• Doctor (MBBS/Specialist)
• Nurse/ANM
• CHO
• Skilled Birth Attendant (SBA)
• Dai/TBA (Traditional Birth Attendant)
• Family member
• Self/Unassisted

• Mandatory
• Single selection
• If "Dai/TBA", "Family member", or "Self" → Show alert: "Unskilled delivery. High-risk PNC needed."

Mode of Delivery

Dropdown

• Normal Vaginal Delivery (NVD)
• Vacuum/ Forceps Assisted
• Lower Segment Cesarean Section (LSCS)
• Emergency LSCS
• Vaginal Birth After Cesarean (VBAC)

• Mandatory
• Single selection
• If LSCS/ emergency LSCS/ Assisted→ Enable "Indication for LSCS" field

Indication for LSCS/Emergency LSCS/Assisted

Multi-select checkbox

• Fetal distress
• Cephalopelvic disproportion (CPD)
• Previous LSCS
• Malpresentation (Breech/Transverse)
• Prolonged/Obstructed labor
• Antepartum hemorrhage (APH)
• Pre-eclampsia/Eclampsia
• Cord prolapse
• Failed induction
• Multiple pregnancies
• Maternal request
• Other (specify)

• Enable only if Mode of Delivery = LSCS/Assisted
• Mandatory if enabled
• Multiple selections allowed
• If "Other" → Enable text field (200 char)

Mother's Condition Immediately Post-Delivery

Radio button

• Healthy/ Stable
• Complication (specify)
• Critical/ICU admission
• Maternal Death

• Mandatory
• If selected "Complications" or "Critical" → Enable maternal complications field.
• If "Maternal Death" → open maternal death audit form
• If "Maternal Death" → Show alert "Inform District Nodal Officer" automatically

Maternal Complications

Multi-select checkbox

• Post-Partum Hemorrhage (PPH)
• Retained placenta
• Perineal tear (1st/2nd degree)
• Perineal tear (3rd/4th degree)
• Uterine rupture
• Sepsis/ Infection
• Pre-eclampsia/Eclampsia
• Blood transfusion required
• Hysterectomy performed
• Anesthesia complication
• Other

• Mandatory if enabled
• Enable if Mother's Condition Immediately Post-Delivery= "Complications" or "Critical"
• Multiple selections allowed
• If "PPH" or "Uterine rupture" → show alert for PNC monitoring
• If "Hysterectomy" → Automatic family planning counseling adjustment (permanent method done) or take in eligible couple tracking form
• Make it editable, for cases if any further complications occur in future.

Mother currently admitted?

Radio button

• Yes (Still in hospital)
• No (Discharged)

• If "No" → Enable discharge date field

Date of Discharge

Date picker

DD/MM/YYYY

• To be enabled if Mother currently admitted? = "No"
• Mandatory if discharged
• Cannot be before delivery date
• Should be used to calculate first PNC home visit timing

Next Button

• Proceed to vital screen and prescription.

S.No.

Name of Data Field

Field Type

Value/ Options

Validation/ Logic/ Condition

1

Name

Auto-populated

From delivery outcome

• Auto-populate form Delivery outcome
• Display only
• Links to ANC & Delivery history
• Non-editable.

2

Date of Delivery

Auto-populated

From delivery outcome

• Auto-populate form Delivery outcome
• Non editable

3

PNC Visit

Spinner

• 1st Day
• 3rd Day
• 7th Day
• 14th Day
• 21st Day
• 28th Day
• 42nd Day/ 6th Week

• Mandatory
• Single selection
• If any 'Visit Day' or previous visit is submitted, then don't show that 'Visit Day' in the spinner for next visit. eg- if last PNC visit was done on 3^rd day, remove options 1^st and 3^rd day when next PNC visit is conducted.
• Selection should be incremental i.e. 1,3,7,14,21,28,42 days

4

PNC Visit Date

Calendar picker

• Format: dd-mm-yyyy

• Auto-populate this due date by calculating using below logic
• After selecting above 'PNC Visit' and calculate this date from 'date of Delivery'
• Not greater than Today's Date
• Not less than Date of Delivery
• Date of 'next visit' should be incremental
• Date of 'next visit' should not be less than 'previous visit' date (always should be greater than 'previous visit' date)
  
  
  

1. 1st Day - Accept date equal to Date of Delivery
2. 3rd Day – date should be equal to 3^rd day after delivery
3. 7th Day – date should be between Delivery + 7 (-3 and +3 ) in days
4. 14th Day - date should be between Delivery + 14 (-3 and +3) in days.
5. 21st Day - date should be between Delivery + 21 (-3 and +3 ) in days.
6. 28th Day - date should be between Delivery + 28 (-3 and +3 ) in days
7. 42nd Day - date should be between Delivery + 42 (-3 and +3 ) in days

5

Maternal Death

Radio Button

• Yes
• No

• Mandatory
• Default value is "No"
• If "Yes" is selected, enable Q.6 to Q.10 and close the case by directly going to the submit option.
• If "No" is selected, disable Q.6 to Q.10 and enable from Q.11 onwards
• If "Yes" is selected, enable below three fields and mark it mandatory
  
  1. Probable Cause of Death
  2. Date of Death
  3. Place of Death
• If "Yes" is selected, update 'Beneficiary Status' = "Death" in the Beneficiary record, with "Death Date", "Place of Death" and "Reason for Death" in Beneficiary table and sync to AMRIT
• If "Yes" is selected, then disable below fields from S. No. 11 to 20 (are Not applicable)

6

Date of Death

Date Picker

• Choose the date from the calendar
• Format: dd-mm-yyyy

• Mandatory if enabled
• Enable if 'Maternal Death' = "Yes"
• Not greater than Today's Date
• Not less than Delivery Date

7

Cause of maternal death

Spinner

• Eclampsia
• Hemorrhage (PPH)
• Anaemia
• High fever
• Sepsis
• Accident
• Other

• Mandatory if enabled
• Enable if 'Maternal Death' = "Yes"
• Open "Other Death Cause" Text Box on selection of "Any Other" option and is mandatory.
• If "Accident" is selected mark it as "Non-maternal death"

8

Other

Text

• Enable only if "cause of maternal death" = "Other"
• Accept alphabets only
• Character limit 50

9

Place of Death

Spinner

• Home
• Subcenter
• PHC
• CHC
• District Hospital
• Medical College Hospital
• Private Hospital
• In Transit
• Other

• Mandatory if enabled.
• Enable if 'Maternal Death' = "Yes"
• If 'Place of Death' is selected as "Other" then enable next field, otherwise don't.

10

Other Place of Death

Textbox

• Mandatory if enabled.
• Enable If 'Place of Death' = "Other"
• Accept alphabets only
• Character limit 50

11

Maternal Symptoms

Dropdown

• Excessive bleeding
• Foul-smelling discharge
• Fever
• Severe abdominal pain
• Breast pain
• Painful urination
• Severe headache
• Dizziness
• Difficulty breathing
• Swelling
• Wound pain
• Mood changes
• None
• Other

• Mandatory.
• Multiple selection
• If 2 or more symptoms selected → show alert for referral to facility
• If "other" is selected enable next field, otherwise don't.

12

Other maternal symptoms

Text

• To be enabled if "Maternal Symptoms" = "Other"
• Accept alphabets only
• Character limit 50

13

Pallor (Anemia check)

Dropdown

• None
• Mild
• Moderate
• Severe

• If pallor= "Severe" → show alert for referral to facility

14

Vaginal Bleeding

Dropdown

• Normal
• Heavy bleeding
• Foul-smelling discharge
• Scanty
• Stopped

• Heavy bleeding or foul smell → show alert for referral to facility

15

Family planning method used by the couple after delivery to avoid pregnancy?

Spinner

Choose:

• Post partum iucd (PPIUCD)
• Condom
• Male sterilization
• Female sterilization
• Post partum sterilization (PPS)
• Minilap
• None
• Other

• Default value is select
• If "Other" is selected then enable " Other contraception method " Text Box below and is mandatory.
• If 'Method of Contraception' = "MALE STERILIZATION" or "FEMALE STERILIZATION" or "POST PARTUM STERILIZATION (PPS)" or "Minilap", then from next PNC visits fields 'Any Method of Postpartum Contraception (PPC)', 'Method of Contraception' and 'Date of Sterilisation' should be disables and show last visit details.
• If 'Method of Contraception' is "FEMALE STERILIZATION" or "POST PARTUM STERILIZATION (PPS)" or "Minilap" is selected, then update 'Status of Women' to "Permanently Sterilized" after submission of 42nd Day PNC visit or after 60 Days from Date of Delivery

16

Other contraception method

Text Box

• Mandatory if enabled
• Accept alphabets, numeric and special character
• Character limit 50

17

Date of Sterilization

Calendar

dd-mm-yyyy

• Enable only If 'Method of Contraception' is "FEMALE STERILIZATION" or "MALE STERILIZATION" or "Minilap" or "POST PARTUM STERILIZATION (PPS)"
• Mandatory
• Not greater than Today's Date
• Accept date not less than Date of Delivery

18

No. of IFA Tablets given

Custom Number Picker

• Default value 0
• IFA supplementation- 180 days postpartum recommended
• Accept numeric (integer) value only
• Accept value greater than 0
• Accept value up to 400

19

Calcium supplementation

Custom Number Picker

• Must accept numeric (integer) value only
• Default Value 0
• Default Value: to be null if no data is entered
• Accept value up to 400

20

Next Button

• Proceed to vital screen and prescription.

S. No.

Data Field

Field Type

Value/Options

Validation / Logic

1

Number of neonates

Dropdown

• Single (1)
• Twins (2)
• Triplets (3)
• Quadruplets+ (4+)

• Mandatory
• If >1 → Duplicate baby outcome section for each baby
• Multiple births flagged for special PNC attention
• This module should be filled separately for each live neonate and generate unique ID for each neonate linked to the same Delivery ID

2

Outcome at Birth

Radio button

• Live Birth
• Still Birth (Macerated)
• Still Birth (Fresh)
• Died during delivery

• Mandatory
• If stillbirth/died → open stillbirth audit form and disable remaining fields
• If stillbirth/ died → Skip growth parameters, go to complications section
  
  
  

3

Sex

Radio button

• Male
• Female
• Ambiguous

• Mandatory
• If "Ambiguous" → Show alert for pediatric specialist referral

4

Cried immediately after birth?

Radio button

• Immediate cry
• Cried after resuscitation
• Not applicable (Stillbirth)

• To be enabled if Q.2 = "Live Birth"
• Mandatory
• If "cried after resuscitation" enable "type of resuscitation" field.
  
  
  

5

Type of resuscitation

Dropdown

• Stimulation
• Suctioning
• Bag and mask ventilation
• Oxygen
• Intubation
• Chest compressions
• Medications

• Mandatory if enabled
• To be enabled if Q.4 = "cried after resuscitation"
• Multiple selections allowed

6

Birth Weight

Number

Capture in grams

• Mandatory
• Validation:
• Must be between 500-6000g
  
  
  
• If <2500g → show alert for "Low Birth Weight (LBW)"
  
  
  
• If <1500g → show alert for "Very Low Birth Weight (VLBW)"
  
  
  
• If <1000g → show alert for "Extremely Low Birth Weight (ELBW)"
  
  
  
• If >4000g → show alert for "Macrosomia" (flag for maternal GDM screening)

7

Any congenital anomaly detected?

Radio button

• Yes
• No
• Suspected (under evaluation)

• If "Yes" or "Suspected" → Enable type of congenital anomaly field

8

Type of congenital anomaly

Dropdown

• Neural tube defect (Spina bifida/Anencephaly)
• Cleft lip/palate
• Club foot
• Down syndrome (suspected)
• Congenital heart defect (suspected)
• Limb defects
• Abdominal wall defect
• Genital abnormality
• Other

• Mandatory if enabled
• To be enabled if Q7. = "Yes" or "Suspected"
• Multiple selections to be allowed
• Enable text field for "Other" specification

9

Other

Textbox

Free text (300 character limit)

• Mandatory if enabled
• To be enabled if type of congenital anomaly= "Other"

10

Newborn Complications

Dropdown

• Birth asphyxia
• Respiratory distress
• Neonatal jaundice (visible at birth)
• Sepsis (suspected)
• Hypothermia
• Hypoglycemia
• Bleeding
• Convulsions
• None

• Multiple selections allowed
• Any complication → show alert for immediate pediatric/ specialist review

11

Current Status of Baby

Radio button

• Healthy and with mother
• Admitted (SNCU/NICU)
• Admitted (General ward)
• Died

• Mandatory
• If "Died" → open neonatal death audit form
• If "Died" enable Q.12 and disable Q.14 to Q.18
• If admitted → show alert for PNC counseling
• If "Healthy and with mother" enable directly Q. 14

12

If baby died, cause of death

Multi-select checkbox

• Birth asphyxia
• Prematurity
• Low birth weight complications
• Sepsis
• Congenital anomaly
• Respiratory distress
• Unknown
• Other (specify)

• Enabled if Current Status of Baby
  
  = "Died"
• Mandatory if enabled
• Multiple causes can contribute
• Enable text field for "Other" specification

13

Other

Textbox

Free text (300 character limit)

• To be enabled if cause of death of baby= "Other"

14

Birth dose vaccines given?

Dropdown

• BCG
• Hepatitis B (Birth dose)
• OPV-0
• None

• Mandatory
• Multiple selections allowed
• If "None" → enable Q.15 to capture the reason for not giving birth dose vaccines

15

Reason for not giving birth dose vaccines

Text field

Free text (200 char)

• Mandatory if enabled
• To be enabled if Q14 = "None"
• Common reasons: Baby unstable, SNCU admission, vaccine unavailable

16

Vitamin K injection given?

Radio button

• Yes
• No

• Mandatory
• If "No" → Enable Q.17 to capture reason for not giving Vitamin K injection

17

Reason for not giving Vitamin K injection

Text field

Free text (200 char)

• To be enabled if Q16 = "No"
• Mandatory if enabled
• Common reasons: Baby unstable, SNCU admission, vaccine unavailable

18

Birth Certificate issued?

Radio button

• Yes
• In process
• No (Not applied)

• Mandatory
• If "No (Not applied)" → show alert to provide information to family stating that birth registration is a legal requirement

19

Next Button

• Proceed to vital screen and prescription.

Data Field

Field Type

Values / Options

Validation / Logic

Difficulty Hearing

• Yes
• No

• Mandatory
• If Difficulty Hearing= "yes" then enable next field "Whisper test response"

Whisper Test Response

Dropdown

• Correct
• Incorrect

• Mandatory if enabled
• To be enabled if Difficulty Hearing= "yes".

Hearing Test Outcome

Dropdown

• Normal
• Slight Loss
• Moderate
• Severe
• Deaf

• Any option other than normal is selected show alert for referral to specialist at the secondary level.

Earache/Ear Pain

• Yes
• No

• Mandatory

Ear Discharge Present

• Yes
• No

• Mandatory

Foreign Body present in Ear

• Yes (superficial)
• Yes (Deep)
• No

• Optional
• If selected Yes (Deep) then show alert for referral to specialist at the secondary level.

Type of Ear Condition

Dropdown

• Otomycosis
• Otitis Externa
• Acute Ear Discharge
• Chronic Ear Discharge
• Ear Wax

• Mandatory
• Multiple selection

Congenital Ear Malformation

• Yes
• No

• Optional
• If selected Yes then show alert for referral to specialist at the secondary level.

Next Button

• Proceed to vital screen and prescription.

Data Field

Field Type

Values / Options

Validation / Logic

Difficulty in breathing

• Yes
• No

• Mandatory
• If Yes, show alert to diagnose URI/rhinitis/sinusitis and refer to specialist if not manageable at HWC.

Open Mouth Breathing

• Yes
• No

• Mandatory
• If Yes, show alert to diagnose URI/rhinitis/sinusitis and refer to specialist if not manageable at HWC.

Nose Bleed (Epistaxis)

• Yes
• No

• If Yes, enable fields, "Systolic BP" and "Diastolic BP"

Systolic BP

Textbox

• mmHg

• To be enabled if nose bleed= "yes"
• Mandatory if enabled
• If more than 120 mm Hg then show alert for referral to specialist at the secondary level.

Diastolic BP

Textbox

• MmHg

• To be enabled if nose bleed= "yes"
• Mandatory if enabled
• If more than 80 mm Hg then show alert for referral to specialist at the secondary level.

Foreign Body Nose

Yes/No

• Yes (anterior visible)
• Yes (posterior visible)
• No

• Optional
• If Yes (posterior visible) is selected show alert for referral to specialist at the secondary level.

Sinusitis

• Yes (facial pain/tenderness)/
• No

• Mandatory
• show alert for referral to specialist at the secondary level for chronic cases.

Next Button

• Proceed to vital screen and prescription.

Name of Data Field

Field Type

Value / Options

Validation / Logic

Is the patient diabetic?

• Yes
• No

• Mandatory
• If Yes, enable "Screening Performed for Diabetic Patient".
• If No, go directly to Visual acuity chart used field.

Screening Performed for Diabetic Patient

• Yes
• No

• Mandatory if enabled
• If Yes, distance Visual Acuity right eye and left eye is mandatory to be filled even if no other complaint.

Visual Acuity Chart Used

Dropdown

• Snellen's distance chart
• Near vision chart

• To be enabled if Is the patient diabetic= "No"
• Mandatory
• Single selection

Distance Visual Acuity – Right Eye

Dropdown

• 6/6
• 6/9
• 6/12
• 6/18
• 6/24
• 6/36
• 6/60
• <6/60

• Will be enabled if Is the patient diabetic= "Yes" and if Visual acuity chart used= "Snellen's distance chart"
• Mandatory
• Single selection
• If 6/18 or above options are selected, show alert for "suspected visual impairment", enable module on case identification

Distance Visual Acuity – Left Eye

Dropdown

• 6/6
• 6/9
• 6/12
• 6/18
• 6/24
• 6/36
• 6/60
• <6/60

• Will be enabled if Is the patient diabetic= "Yes", if Visual acuity chart used= "Snellen's distance chart"
• Mandatory
• Single selection
• If 6/18 or above options are selected, show alert for "suspected visual impairment", enable module on case identification

Near Visual Acuity

Dropdown

• N6
• N8
• N10
• N12

• Will be enabled if Visual acuity chart used= "Near Vision chart"
• Mandatory
• Single selection
• if reduced near vision with otherwise normal eye exam in adults, enable module on case identification

Next Button

• Proceed to vital screen and prescription only if case identification module is not enabled by any of the fields in this module.

Name of Data Field

Field Type

Value / Options

Validation / Logic

Case Identification and Condition(s)

Multi-select

• Cataract
• Glaucoma
• Diabetic retinopathy
• Presbyopia
• Trachoma
• Corneal disease
• Conjunctivitis/Acute red eye
• Dry eye/ xerophthalmia
• Eye allergy

• Mandatory if visit type= "symptomatic", Visual acuity >= 6/18

Cataract symptoms

• Yes
• No

• Enabled if Case Identification and conditions= "Cataract"
• If yes= show alert for referral to Ophthalmologist at the secondary level.

Glaucoma symptoms

• Yes
• No

• Enabled if Case Identification and conditions= "Glaucoma"
• If yes= show alert for referral to Ophthalmologist at the secondary level.

Diabetic retinopathy symptoms

• Yes
• No

• Enabled if Case Identification and conditions= "Diabetic retinopathy"
• If yes= show alert for referral to Ophthalmologist at the secondary level.

Presbyopia Symptoms

• Yes
• No

• Enabled if Case Identification and conditions= "Presbyopia"
• If yes then can qualify for presbyopia management (e.g., reading glasses) as per service scope of CHO.

Trachoma Status

Dropdown

• Suspected active trachoma
• Suspected TT/TI
• No trachoma

• Enabled if Case Identification and conditions= "Trachoma"
• If suspected active trachoma or Suspected TT/TI is selected, show alert for referral to Ophthalmologist at the secondary level

Corneal Disease Type

Dropdown

• Corneal opacity
• Corneal ulcer suspected
• Other corneal pathology

• Enabled if Case Identification and conditions= "Corneal disease"
• Any selection- show alert for referral to Ophthalmologist at the secondary level

Vitamin A Deficiency symptoms / Bitot's Spot Identified

• Yes
• No

• Enabled if Case Identification and conditions=
  
  "Dry eye/ xerophthalmia
  "
• If Yes, Vitamin A prophylaxis to be given and show alert for referral to Ophthalmologist at the secondary level

Next Button

• Proceed to vital screen and prescription.

Name of Data Field

Field Type

Value / Options

Validation / Logic

Injury Type

Multi-select

• Mechanical foreign body
• Blunt trauma
• Penetrating injury suspected
• Chemical (acid/alkali/other)

• Mandatory
  .

Foreign Body Removal Attempted

Dropdown

• Not attempted
• Attempted from conjunctival sac
• Foreign body lodged in cornea

• Optional
• If selected Foreign body lodged in cornea - show alert for referral to Ophthalmologist at the secondary level.

Chemical Exposure – Thorough Wash Performed

• Yes
• No

• Show alert for referral to Ophthalmologist at the secondary level.

Next Button

• Proceed to vital screen and prescription.

Data Field

Field type

Value/ Options

Validation/ Logic

Tooth Decay Present

• Yes
• No

• Mandatory
• If selected Yes, enable the field "Symptoms of tooth decay"

Symptoms of tooth decay

Dropdown

• Black spot
• Discoloration of tooth Cavity
• Hole in the tooth
• Sensitivity to hot and cold, sweet and sour
• Food lodgment in the cavity/
  
  between teeth
• Pain
• Swelling
• Pus discharge

• To be enabled if Tooth Decay present= "Yes"
• Multiple selection
• Mandatory if enabled
• If yes, Show alert show for referral to Dentist at the secondary level.

Gum Diseases Present

• Yes
• No

• Mandatory
• If selected Yes, enable the field "Symptoms of Gum diseases"

Symptoms of Gum diseases

Dropdown

• Foul smell
• Bleeding gums
• Deposits and discoloration of tooth
• Loose teeth
• Widening gap between teeth
• Swollen gums

• To be enabled if Gum diseases present= "Yes"
• Multiple selection
• Mandatory if enabled
• Show alert for referral to Dentist at the secondary level.

Irregular Teeth/Jaws

• Yes
• No

• Optional
• If yes, Show alert for referral to Dentist at the secondary level.

Abnormal Growth/Ulcer

• Yes
• No

• Optional
• If yes, Show alert for referral to Dentist at the secondary level.

Cleft Lip/Palate

• Yes
• No

• Optional
• If yes, Show alert for referral to Dentist at the secondary level.

Dental Fluorosis

• Yes
• No

• Optional
• If yes, Show alert for referral to Dentist at the secondary level.

Dental Emergency

Dropdown

• Pain
• Abscess
• Swelling
• Tooth Injury
• Avulsion
• Non-Healing Ulcer
• Uncontrolled Bleeding
• Trauma (Fractured jaw/mobile teeth)

• Optional
• Show alert for referral to Dentist at the secondary level.

Next Button

• Proceed to vital screen and prescription.

S. No.

Data Field

Field Type

Value / Options

Validation / System Logic

1

Emotional or behavioural concerns present

Radio

Yes / No

Mandatory

System Behaviour

Auto

—

If Yes → Enable PHQ9 screening

2

Substance use related concerns present

Radio

Yes / No

Mandatory

System Behaviour

Auto

—

If Yes → Enable Substance Use Screening & Brief Intervention

3

Thoughts of self-harm or suicide present

Radio

Yes / No

Mandatory

System Behaviour

Auto

—

If Yes → Immediately enable PHQ 9 form and then Suicide Risk Screening

4

Memory loss or confusion present

Radio

Yes / No

Mandatory

System Behaviour

Auto

—

If Yes → Enable Dementia Screening Checklist

5

Seizures, fits, or loss of consciousness present

Radio

Yes / No

Mandatory

System Behaviour

Auto

—

If Yes → Enable Epilepsy Screening Checklist

6

Post-partum woman (≤12 months after delivery)

Auto (from RMNCH+A)

Yes / No

Auto-derived

System Behaviour

Auto

—

If Yes → Auto-prompt Depression Screening (PHQ-9) for Post-partum Depression

Data Field

Field Type

Value / Options

Validation / Logic

PHQ-9 Question 1–9

Radio (each question)

Not at all (0), Several days (1), More than half the days (2), Nearly every day (3)

Mandatory

PHQ-9 Total Score

Auto

0–27

Auto-calculated as sum of Q1–Q9

Depression Severity

Auto

Minimal / Mild / Moderate / Moderately Severe / Severe

Derived from total score

System Action

Auto

Psychoeducation / Counselling / Referral

Triggered based on severity category

Referral Alert

System alert

—

If PHQ-9 ≥10 → Refer to MO/PHC; if PHQ-9 ≥15 → Urgent referral; if PHQ-9 ≥20 → Emergency referral

Post-partum Depression Screening Trigger

Auto (RMNCH+A linkage)

≤12 months after delivery

If Yes → PHQ-9 screening is mandatory irrespective of chief complaint

Data Field

Field Type

Value / Options

Validation / System Logic

Thoughts of self-harm or suicide

Radio

Yes / No

Mandatory

Previous suicide attempt

Radio

Yes / No

Mandatory if "Thoughts of self-harm or suicide" = Yes

Current intent or plan

Radio

Yes / No

Mandatory if "Thoughts of self-harm or suicide" = Yes

Access to means

Radio

Yes / No

Mandatory if "Thoughts of self-harm or suicide" = Yes

CHO assesses immediate risk

Radio

Yes / No

Mandatory; based on CHO clinical judgement

Suicide Risk Level

Auto

Low / Moderate / High

Auto-derived from responses and CHO judgement

Referral alert

System alert

—

Mandatory referral if risk level = Moderate or High

S. No.

Data Field

Field Type

Value / Options

Validation / System Logic

1

Current tobacco use

Radio

Yes / No

Mandatory

2

Type of tobacco use

Dropdown

Smoking / Smokeless / Both

Mandatory if Current tobacco use = Yes

3

Frequency of tobacco use

Dropdown

Occasional / Daily

Mandatory if Current tobacco use = Yes

4

Tobacco use outcome

Auto

Use identified / No use identified

Auto-derived

5

System action

Auto

Brief counselling / Close screening

If use identified → enable brief counselling

S. No.

Data Field

Field Type

Value / Options

Validation

1

Current alcohol use

Radio

Yes / No

Mandatory

2

Frequency of alcohol use

Dropdown

Occasional / Regular / Daily

Mandatory if Current alcohol use = Yes

3

Loss of control over drinking

Radio

Yes / No

Mandatory if Current alcohol use = Yes

4

Impact on daily functioning (health, family, work)

Radio

Yes / No

Mandatory if Current alcohol use = Yes

5

Symptoms suggestive of withdrawal

Radio

Yes / No

Mandatory if Current alcohol use = Yes

6

CHO assessment of problematic alcohol use

Radio

Yes / No

Mandatory

7

Alcohol use classification

Auto

Problematic / Non-problematic

System-derived

8

System action

Auto

Brief intervention / Referral

Based on classification

Data Field

Field Type

Value / Options

Validation / Logic

Episodes of loss of consciousness

Checkbox

Yes

Optional

Recurrent jerky movements / fits

Checkbox

Yes

Optional

Progressive memory loss

Checkbox

Yes

Optional

Confusion / disorientation

Checkbox

Yes

Optional

Functional decline (daily activities)

Checkbox

Yes

Optional

Screening Outcome

Auto

Suspected / Not suspected

If ANY checkbox selected → Suspected

Referral Required

Auto

Yes / No

Mandatory if suspected

Data Field

Field Type

Value / Options

Validation / Logic

Psychosocial intervention provided

Radio

Yes / No

Mandatory

Type of intervention

Multi-select

Psychoeducation, Counselling, Stress management, Family counselling

Mandatory if Yes

Session date

Date

dd-mm-yyyy

Cannot exceed current date

Duration (minutes)

Numeric

10–60

Mandatory

Remarks

Text

250 chars

Optional

Data Field

Field Type

Validation / Logic

Referral required

Radio

Yes / No

Referral level

Dropdown

PHC / DMHP / De-addiction centre

Reason for referral

Dropdown

Alcohol dependence suspected, Withdrawal symptoms, Medical complications

Referral date

Auto

System generated

Data Field

Field Type

Value / Options

Validation / Logic

Follow-up required

Radio

Yes / No

Mandatory

Follow-up date

Date

dd-mm-yyyy

Mandatory if Yes

Improvement noted

Radio

Improved / Same / Worse

Mandatory

Repeat PHQ-9

Same as baseline

—

As applicable

Referral escalation required

Radio

Yes / No

Mandatory

Case closure reason

Dropdown

Recovered / Referred / Lost to follow-up / Death

Mandatory on closure

Data Field

Field Type

Value / Options

Validation / Logic

General geriatric complaints present

Radio

Yes / No

Mandatory

Multiple chronic conditions

Checkbox

Yes

Optional

Recent falls

Checkbox

Yes

Optional

Difficulty in walking / balance

Checkbox

Yes

Optional

Visual or hearing difficulty

Checkbox

Yes

Optional

Functional decline / difficulty in daily activities (ADL)

Radio

Yes / No

Mandatory

If Functional decline = Yes

Auto

—

Enable Functional Assessment section

Memory loss or confusion

Radio

Yes / No

Mandatory

If Memory loss = Yes

Auto

—

Enable Dementia Screening Checklist

Referral alert

System Alert

—

Show alert if functional decline or memory loss present

Data Field

Field Type

Value / Options

Validation / Logic

Progressive memory loss

Checkbox

Yes

Optional

Disorientation (time/place/person)

Checkbox

Yes

Optional

Behavioural changes

Checkbox

Yes

Optional

Decline in self-care / routine activities

Checkbox

Yes

Optional

Screening Outcome

Auto

Suspected / Not suspected

Suspected if ANY one selected

Referral Required

Auto

Yes / No

Mandatory if suspected

Data Field

Field Type

Value / Options

Validation / Logic

Persistent pain present

Radio

Yes / No

Mandatory

If Pain present = Yes

Auto

—

Enable Pain Assessment section

Distressing symptoms present

Checkbox

Breathlessness / Nausea / Fatigue / Weakness / Other

Optional

Bedridden or severely dependent

Radio

Yes / No

Mandatory

Life-limiting or chronic illness known

Radio

Yes / No

Mandatory

Caregiver support required

Radio

Yes / No

Mandatory

If ANY of the above = Yes

Auto

—

Enable Palliative Care Assessment

Data Field

Field Type

Value / Options

Validation / Logic

Pain severity

Dropdown

Mild / Moderate / Severe

Mandatory

Pain duration

Dropdown

<1 month / 1–6 months / >6 months

Mandatory

Other symptoms severity

Dropdown

Mild / Moderate / Severe

Mandatory if symptoms present

Immediate relief provided

Radio

Yes / No

Mandatory

Referral alert

System Alert

—

Show alert if pain = Severe or symptoms uncontrolled

Data Field

Field Type

Value / Options

Validation / Logic

Psychosocial counselling provided

Radio

Yes / No

Mandatory

Caregiver counselling provided

Radio

Yes / No

Mandatory

Caregiver distress identified

Checkbox

Yes

Optional

Counselling remarks

Text

250 characters

Optional

Data Field

Field Type

Value / Options

Validation / Logic

Referral required

Radio

Yes / No

Mandatory

Referral level

Dropdown

PHC / CHC / District Hospital / Palliative Care Unit

Mandatory if Yes

Reason for referral

Dropdown

Severe pain / Functional dependence / Dementia suspected / End-of-life care

Mandatory

Follow-up required

Radio

Yes / No

Mandatory

Follow-up date

Date

dd-mm-yyyy

Mandatory if follow-up required

Data Field

Field Type

Value / Options

Validation / Logic

Case status

Dropdown

Under care / Referred / Stable / Death

Mandatory

Date of death (if applicable)

Date

dd-mm-yyyy

Mandatory if status = Death

Remarks

Text

250 characters

Optional

Affected Body Part

Chief Complaint

Ear

• Ear Pain
• Ear discharge
• Difficulty in hearing
• Ear wax
• Congenital Ear Malformation
• Foreign body in ear.

Nose

• Pain
• Nasal discharge
• Difficulty in breathing
• open mouth breathing
• Sinusitis
• Nosebleed
• Foreign body in nose.

Throat

• Neck swelling
• Dysphagia
• Hoarseness
• Cleft lip
• Cleft palate
• Tonsillitis
• Pharyngitis
• Laryngitis
• Sinusitis.

Eye/ Ophthalmic

• Diabetic retinopathy
• Glaucoma
• Cataract
• Presbyopia
• Trachoma
• Corneal disease
• Conjunctivitis/Acute red eye
• Dry eye/ xerophthalmia
• Eye allergy
• Eye injuries from blunt trauma, penetrating injury to eye,
• Chemical exposure (acid/ alkali/other),
• Foreign body lodged in the eye

Oral Health

• Dental Decay
• Gum diseases
• Irregular arrangement of teeth and jaws
• Abnormal growth, patch or ulcers
• Cleft lip/ palate
• Dental Fluorosis
• Dental Emergencies

Category

Condition

Chief Complaints

Common Mental Disorders (CMD)

Depression

Persistent sadness or low mood; Loss of interest in daily activities; Fatigue or low energy; Sleep disturbances; Poor appetite or overeating; Feelings of worthlessness or guilt; Difficulty concentrating

Anxiety / Panic Disorders

Excessive worry or fear; Restlessness; Palpitations; Shortness of breath; Chest tightness; Trembling or sweating; Sudden panic episodes

Somatisation Disorders

Multiple body pains without clear cause; Headache; Back pain; Abdominal pain; Generalised weakness; Repeated physical complaints despite normal reports

Severe Mental Disorders (SMD) (Screen & Refer)

Schizophrenia

Hearing voices; Seeing things others cannot see; Suspiciousness or fear without reason; Talking irrelevantly; Social withdrawal; Poor self-care

Bipolar Disorder

Episodes of extreme happiness or irritability; Reduced need for sleep; Excessive talking or activity; Risk-taking behaviour; Alternating low mood and high energy

Severe Depression

Persistent low mood with inability to function; Marked withdrawal; Poor self-care; Hopelessness; Suicidal thoughts

Substance Use Disorders (SUD)

Alcohol Use Disorder

Regular alcohol consumption; Loss of control over drinking; Morning drinking; Family or work problems due to alcohol; Tremors or withdrawal symptoms

Tobacco Use Disorder

Daily smoking or tobacco chewing; Craving for tobacco; Inability to quit despite advice; Health complaints linked to tobacco use

Suicide Risk / Ideation

—

Thoughts of self-harm; Thoughts of ending life; Previous suicide attempt; Expressed hopelessness; Statements about being a burden

Neurological Conditions (Screen & Refer)

Epilepsy

Fits or seizures; Loss of consciousness; Jerky movements; Tongue bite or incontinence during episode; Confusion after episode

Dementia

Progressive memory loss; Forgetting recent events; Disorientation to time/place; Difficulty managing daily activities; Behavioural changes

Maternal Mental Health

Post-partum Depression

Persistent sadness after childbirth; Excessive crying; Irritability; Difficulty bonding with baby; Sleep problems unrelated to infant care; Feelings of inadequacy

S. No.

PHQ-9 Question

Field Type

Response Options

1

Little interest or pleasure in doing things

Radio Button

Not at all (0) / Several days (1) / More than half the days (2) / Nearly every day (3)

2

Feeling down, depressed, or hopeless

Radio Button

Not at all (0) / Several days (1) / More than half the days (2) / Nearly every day (3)

3

Trouble falling or staying asleep, or sleeping too much

Radio Button

Not at all (0) / Several days (1) / More than half the days (2) / Nearly every day (3)

4

Feeling tired or having little energy

Radio Button

Not at all (0) / Several days (1) / More than half the days (2) / Nearly every day (3)

5

Poor appetite or overeating

Radio Button

Not at all (0) / Several days (1) / More than half the days (2) / Nearly every day (3)

6

Feeling bad about yourself — or that you are a failure or have let yourself or your family down

Radio Button

Not at all (0) / Several days (1) / More than half the days (2) / Nearly every day (3)

7

Trouble concentrating on things, such as reading the newspaper or watching television

Radio Button

Not at all (0) / Several days (1) / More than half the days (2) / Nearly every day (3)

8

Moving or speaking so slowly that other people could have noticed, or being unusually restless

Radio Button

Not at all (0) / Several days (1) / More than half the days (2) / Nearly every day (3)

9

Thoughts that you would be better off dead or of hurting yourself in some way

Radio Button

Not at all (0) / Several days (1) / More than half the days (2) / Nearly every day (3)

Score

Severity

System Action

0–4

Minimal

Psychoeducation

5–9

Mild

Counselling + follow-up

10–14

Moderate

Refer to MO

15–19

Moderately Severe

Urgent referral

20–27

Severe

Emergency referral

High Risk Pregnancy (HRP) Conditions that warrant immediate referral to the higher centre.

History of abortions

Any complications in previous pregnancy

• Gestational Diabetes
• Pre-eclampsia
• Eclampsia
• Hemorrhage
• Preterm Birth
• Stillbirth

Height if <145 cm

Pre-existing conditions 

• Hypertension
• Diabetes Mellitus
• Thyroid
• Heart disease
• Epilepsy
• Tuberculosis
• HIV
• Sexually transmitted Infections
• Severe Malnutrition
• Kidney disease
• Auto Immune disorders
• Hepatitis B

Danger Signs

• Vaginal Bleeding
• Swelling of hands, feet or face
• Severe Headache
• Blurred Vision
• Convulsions/ seizures
• Severe abdominal pain
• Fever > 38°C
• Painful urination/ Burning
• Reduced fetal movement
• Vaginal fluid leakage
• Persistent vomiting
• Breathlessness/ chest pain