COMMUNITY BASED ASSESSMENT CHECKLIST (CBAC)

General Information :
Name of ASHA :
Village/Ward Date :
Name of MPW/ANM :
AYUSH Health & Wellness Centre :
Personal Details :
Name : Any Identifier (Aadhar Card/any other UID-Voter ID etc):

Age: State Health Insurance Scheme : Yes/No if yes, specify:

Sex : Telephone No. (self/family member / other - specify details):

Address:
Does this person have any of the following : If yes, Please specify
visible defect/known disability/Bed Ridden/Require
Support for Activities of Daily Living

Part A : Risk Assessment

Question Range Circle Write Score
1. What is your age ? (in 0 - 29 years 0
complete years) 30 - 39 years 1
40 - 49 years 2
50 - 59 years 3
>60 years 4
2. Do you smoke or consume Never 0
smokeless products such as Used to consume in the past / 1
gutka or khaini? Sometimes now
Daily 2
3. Do you consume alcohol No 0
daily Yes 1
4. Measurement of waist (in Female Male
cm) 80 cm or less 90 cm or less 0
81-90 cm 91-100 cm 1
More than 90 cm More than 100 cm 2
5. Do you undertake any At least 150 minutes in a week 0
physical activities for
minimum of 150 minutes in
a week?
(Daily minimum 30 minutes
Less than 150 minutes in a week 1
per day - Five days a week)
6. Do you have a family history
(any one of your parents of No 0
siblings) of high blood
pressure, diabetes and heart Yes 2
disease?
Total Score
Every individual needs to be screened irespective of their scores.
A score above 4 indicates that the person may be at higher risk of NCDs and needs to be prioritized for attending the weekly screening day

Part B: Early Detection: As if Patient has any of these Symptoms

B1 : Women and Men Y/N Y/N
Shortness of breath (difficulty in breathing) History of fits
Coughing more than 2 weeks* Difficulty in opening mouth
Blood in sputum* Any ulcers in mouth that has not healed
in two weeks
Fever for >2 weeks* Any growth in mouth that has not healed
in two weeks
Loss of weight* Any white or red patch in mouth that has
not healed in two weeks.
Night Sweats* Pain while chewing
Are your currently taking anti-TB drugs* Any change in the tone of your voice
Anyone in family currently suffereing from TB** Any hypopigmented patch(es) or
discolored lesion(s) with loss of sensation
History of TB* Any thickened skin
Recurrent ulceration on palm or sole Any nodules on skin
Recurrent tingling on plam(s) or sole(s) Recurrent nmbness on palm (s) or sole (s)
Cloudy or blurred version Clawing of fingers in hands and / or feet
Difficulty in reading Tingling and numbness in hands and/or feet
Pain in eyes lasting for more than a week Inability to close eyelid
Redness in eyes lasting for more than a week Difficulty in holding objects with hands/
fingers
Difficulty in hearing Weakness in feet that cause difficulty in Walking
B2: Women only Y/N Y/N
Lump in the breast Bleeding after menopause
Blood stained discharge from the nipple Bleeding after intercourse
Change in shape and size or breast For smelling vaginal discharge
Bleeding between periods
B3: Elderly Specific (60 years and above) Y/N Y/N
Feeling unsteady while standing or walking Needing held from others to perform everyday
activities such as eating, getting dressed,
grooming, bathing, walking, or using the toilet

Suffering from any physical disability that Forgetting names of your near ones or your
restrict movement own home address.
In case of individual answers Yes to any one of the above-mentioned symptoms, refer the patient immediately to the nearest
facility where a Medical Officer is available

*If the response is Yes-action suggested: Sputum sample collection and transport to nearest TB testing center

**If the answer is yes, tracing of all family members to be done by ANM/MPW

Part C: Risk factors for COPD

Circle all that apply
Type of fuel used for cooking-Firewood/Crop Residue/Cow dung cake / coal / Kerosene / LPG
Occupational exposure-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 : PHQ 2
Over the last 2 weeks, how often have you Not at Several More than Nearly every
been bothered by the following problems ? all days half the days day

1. Little interest or pleasure in dong things? 0 +1 +2 +3

2. Feeling down, depressed of hopless? 0 +1 +2 +3

Total Score
Anyone with total greater than 3 should be referred to AYUSH Health & Wellness Centre/AYUSH Dispensaries