Community based assessment checklist (CBAC)

Date: DD/MM/YYYY
General Information
Name of ASHA : Village/Ward :
Name of MPW/ANM : Sub Centre :
AYUSH Dispensary : PHC/UPHC :
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 Any Write
Score
1. What is your age? ( in 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 gutka Used to consume in the past/Sometimes now 1
or khaini ? Daily 2
3. Do you consume a alcohol No 0
daily Yes 1
4. Measurement of waist (in cm) Female Male
80 cm or less 90 cm or less 0
81-90 cm 91-100 cm 1
More than 90 cm More than 100 2
cm
5. Do you undertake any At least 150 minutes in a week 0
physical activities for minimum Less than 150 minutes in a week 1
of 150 minutes in a week? (Daily
minimum 30 minutes per day –
Five days a week)
6. Do you have a family history No 0
(any one of your parents or Yes 2
siblings) of high blood pressure,
diabetes and heart disease?
Total Score

Every individual needs to be screened irrespective 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 : Ask 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 you currently taking anti-TB drugs** Any change in the tone of your voice
Anyone in family currently suffering from Any hypopigmented patch(es) or
TB** discoloured 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 palm(s) or sole (s) Recurrent numbness on palm(s) or sole(s)
Cloudy or blurred vision 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 difficultly 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 of breast Foul smelling vaginal discharge
Bleeding between periods

B3 Elderly Specific (60 years and above) Y/N Y/N

Feeling unsteady while standing or walking Needing help from others to perform
everyday activities such as eating, getting
dressed, grooming, bathing, walking, or
using the toilet.
Suffering from and physical disability that Forgetting names of your near ones one
restricts movement your 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 been Not at all Several More than Nearly every
bothered by the following problems? days half the days day
1. Little interest or pleasure in doing things ? 0 +1 +2 +3

2. Feeling down, depressed or hopeless? 0 +1 +2 +3

Total Score

Anyone with total score greater than 3 should be referred to CHO/ MO (PHC/UPHC)