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CBHI Form No. |
03 |
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Monthly |
| MONTHLY
REPORT ON CASES AND DEATHS DUE TO NON-COMMUNICABLE DISEASES IN THE STATE / UT |
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| Name of the State/UT: |
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Reporting
Month & Year: |
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| Total No. of Govt. Secondary, Tertiary
& Super Speciality |
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Total
No. of Govt. Secondary, Tertiary & Super Speciality |
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| Medical Care Institutions in the State/UT :- |
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Medical Care
Institution in the State/Ut reported on |
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Non-Communicable diseases during the reporting
month:- |
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| Sl. |
Nature/
Group |
Total No. of Reported |
Out Door
Patient |
In Door Patient |
Total Patients |
Indoor Deaths |
Total No. of Reported |
| No. |
of |
Cases & Deaths |
During the |
During the |
During the |
during the |
Cases & Deaths |
| |
Non Communicable |
till previous month |
Reporting Month |
Reporting Month |
Reporting Month |
Reporting month |
till the end of
Reporting Month |
| |
Diseases |
Cases |
Deaths |
(New*) Cases |
(New*) Cases |
Cases |
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Cases |
Deaths |
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M |
F |
T |
M |
F |
T |
M |
F |
T |
M |
F |
T |
M |
F |
T |
M |
F |
T |
M |
F |
T |
M |
F |
T |
| 1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
11 |
12 |
13 |
14 |
15 |
16 |
17 |
18 |
19 |
20 |
21 |
22 |
23 |
24 |
25 |
26 |
| |
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9+12 |
10+13 |
11+14 |
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3+15 |
4+16 |
5+17 |
6+18 |
7+19 |
8+20 |
| 1 |
Cardio Vascular Diseases |
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| 1.1 |
Hypertension |
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| 1.2 |
Ischemic
Heart |
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| |
Diseases |
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| 2 |
Neurological Disorders |
| 2.1 |
Cerebro Vascular |
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Accident |
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| 2.2 |
Other Neurological |
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Disorders ** |
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| 3 |
Diabetes Mellitus |
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| 3.1 |
Type 1
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| 3.2 |
Type 2 |
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| 4 |
Lungs Disease |
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| 4.1 |
Bronchitis |
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| 4.2 |
Emphysemas |
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| 4.3 |
Asthma |
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| 5 |
Psychiatric Disorder |
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| 5.1 |
Common Mental
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| |
Disorders |
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| 5.2 |
Severe Mental
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| Disorders |
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| 6 |
Accidental Injuries |
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| 7 |
Cancer |
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| 8 |
Snake
Bite |
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| Total |
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* - New
Registration are to be considered as New Patients |
** - Other Neurological disorders like
Epilepsy, Parkisons Diseases,
Dementia. |
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| M - MALE, F - FEMALE, T - TOTAL |
T - TOTAL |
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Signature |
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| * |
Secondary
Medical / Health Care Institutions: Taluka /CHC/District Hospitals |
Name
& Designation |
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| * |
Tertiary Medical
/ Health Care Institutions: Speciality & Super Speciality Hospital at
Regional/State Level including
attached to Medical Colleges. |
Address with Tele / Fax &
E-Mail |
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| To, The
Director, Central Bureau of Health Intelligence, 401-A Nirman Bhavan, New
Delhi -110011 |
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Tel / Fax: 91-011-2306-2695 / 2306-3175;
E-Mail: dircbhi@nb.nic.in |
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******* |
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