Health Condition Report Form

Pdl.No.12/SBHI-II/s4/2000 MONTHLY STATEMENT SHOWING INSTITUTIONAL CASES AND DEATHS DUE TO COMMUNICABLE DISEASES Name of the Municipality / District : Month / Year : Total Number of existing Institutions in Municipality/ District Total No of Reporting Institutions for the Month in the Municipality : Total No of defaulting Institutions in the Mounth in Municipality :

:

Reported cases & Deaths Due to Communicable Diseases: S.N o

Name of the Diseases

1. 2. 3. 4. 5. 6. 7. 8.

Acute Diarrhoeal Diseases Dipthoria(032) Acute Poliomyelities (045) Tetanus-other than Neonatal (037) Neonatal Tetanus (771.3) Whooping Caugh (033) Measles (055) Acute Respiratory infection including Influenza & excluding phenmonia (460-466) (487) Entric fever (002) Viral Hepatitis (070) Japanese Encephalitin(062.0) Meningococeal Meningitis (036.0),(320.5) @Rabies (071) Pnemonia Syphilis (090) Gonococeal Infection Pulmonary Tuberculosis * All other Diseases treated in Institutions excluding above Mentioned Disease Total

O.P M

9. 10. 11. 12. 13. 14. 15. 16. 17. 18

I.P F

T

M

Deaths F

T

M

F

T

* Including Communicable and Non - Communicable Disease @Please take Care ,Not to include simple dog bite cases.

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