Patients According to Dignosed Institutions

ANNUALRETURNOFLEPROSY STATISTICS

……………………………..DISTRICT

01/01/2015 T0 31/12/2015

At the end of the Year 2015
2014 / 2015 / *Diff %
Registered patients
Children (<15)
Grade 2 disability cases
Multibacillary cases
Females cases
Onset of symptoms < 6month
Age group >55
No of patients notified
No of relapse cases
No of relapse cases investigated
No of defaulters restarted treatment
M.O.H. area / M.O.H
Population / P.H.I. area / Registered cases / MB
cases / Child
cases / Gr 2
cases / Female
cases / Onset of symptoms / Total cases
In MOH
<6m / >2yr
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
Total

CHILD PATIENTS

MOH area / Number of cases / Gr 2
cases / Number of Child cases investigated / Total Number of Contacts of All Child cases / Total Number Of Positive Contact / Total Number contact less than 15 years
01
02
03
04
05
06
Totals

DEFORMITY PATIENTS(includes Gr1 & Gr2)

MOH area / Number of cases / Gr1 / Gr2 / Service Rendered
MCR shoes / Splints/gutters / Ulcer care kits / counseling
hands / feet / Claw hands / Foot drop / Foot ulcer / Eye / Face
01
02
03
Totals

PATIENTS ACCORDING TO DIGNOSED INSTITUTIONS

Diagnosed from institutions Within the district / Diagnosed from institutions Outside the district
Name of the institution / No: of patients / Name of the Satellite clinic / No: of patients / Name of the institution / No: of patients
01
02
03
04
05
Totals / Totals / Totals

PATIENTS FROM OTHER DISTRICTS DIGNOSED FROM INSTITUTION WITHIN THE DISTRICT

District / Diagnosed Institution / Number of patient
01
02
03
04
Total

TREATMENT COMPLECTION BY DIGNOSED YEAR

MB treatment completion / PB treatment completion
Total No of MB diagnosed in 2013 / No of MB diagnosed in 2013 Who has completed treatment 2015 / Total No of PB diagnosed in 2014 / No of PB diagnosed in 2014 Who has completed treatment 2015

DEFAULTER PATIENTS

NIC / Reg: no / Type / MOH area / PHI area / Date of diagnosis
01
02
03

CONTACT EXAMINATION

MOH area / Number of total cases / Number of Notification received (from WER) / Number of contact / Number of contact examined / No referred to dermatology clinic / Number positive / Number not followed up
01
02
03
Total

PATIENTS WITH REACTIONS

Institution / Number of MB / Number of PB / Drugs used for treatment / Total Number of reactions
steroids / clofazamine / Thalidomide
01
02
03
Total

MDT BALANCE FOR WHOLE DISTRICT 31/12/2015

Type of MDT / Stating balance / Stock received / Utilization / Ending balance
MB-A
MB-C
PB-A
PB-C

ACTIVITIES CONDUCTED IN THE DISTRICT DURING 2015

Activity / Source of funds / Output (no of patients seen,number of staff/people trained/educated)
01
02
03

CAPACITY BUILDING - PHLT

Institution / Name of PHLT Trained by ALC / Contact number
Total
Name of the Institution / Institution 1 / Institution 2 / Institution 3 / Institution 4 / Institution 5 / Satellite clinic / District
Totals
Total no of cases Registered
Total No of cases notified
Total no of relapses registered
Total no of Defaulters Re -registered
Total No of Female cases
Total no of MB cases
Total no of child cases <15
no of G2d Cases
Total no of MB cases reg in 2013
Total no of MB complete the treatment 2015 [reg in 2013]
Total no of PB cases reg in 2014
Total no of PB complete the treatment 2015 [reg in 2014]
Reaction type 1 / MB
PB
Reaction type 2 / MB
PB

HEALTH INSTITUTION DATA IN THE DISTRICT

Preparedby –

Date–

……………………………. ……………………………..

R.E‛s signature R.D.H.S.

Signature Signature

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