MONTHLY REPORT ON CASES AND DEATHS DUE TO NON-COMMUNICABLE  DISEASES IN THE STATE / UT CBHI Form No. 03
Monthly
 Name of the State/UT:   Reporting Month & Year:     
 Total No. of Govt. Secondary, Tertiary & Super Speciality     Total No. of Govt. Secondary, Tertiary & Super Speciality     
     Medical  Care Institutions in the State/UT :-     Medical Care Institution in the State/Ut reported on     
    Non-Communicable diseases during the reporting month:-    
Sl. Nature/ Group Out Door Patient In Door Patient Total Patients Indoor Deaths
 No.  of  During the  During the  During the   during the
  Non Communicable Reporting Month   Reporting Month  Reporting Month Reporting month
  Diseases (New*) Cases (New*) Cases Cases  
    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
                3+6 4+7 5+8      
1 Cardio Vascular Diseases  
1.1  Hypertension                        
1.2  Ischemic Heart  Diseases                        
2 Neurological Disorders
2.1  Cerebro Vascular Accident                        
2.2  Other Neurological Disorders **                        
3 Diabetes Mellitus
3.1  Type 1                          
3.2  Type 2                         
4 Lungs Disease
4.1  Bronchitis                        
4.2  Emphysemas                        
4.3  Asthma                        
5 Psychiatric Disorder
5.1  Common Mental Disorders                        
5.2  Severe Mental Disorders                        
6 Accidental Injuries                        
7 Cancer                        
8 Snake Bite                        
  TOTAL                         
* - New Registration are to be considered as New Patients    ** - Other Neurological disorders like Epilepsy, Parkisons Diseases,  Dementia.  
M - MALE,  F - FEMALE,  T - TOTAL Signature      
Secondary Medical / Health Care Institutions: Taluka /CHC/District Hospitals Name & Designation       
Tertiary Medical / Health Care Institutions: Speciality & Super Speciality Hospital at Regional/State Level including  attached to Medical Colleges. Address with telephone / e-mail      
To- Central Bureau of Health Intelligence, 401-A Nirman Bhavan, New Delhi -110011 (E-Mail: dircbhi@nic.in) Tel: 011-23062695