File No.HFW-2703B/B/201B-NHM SEC-Dept.

of H&FW

GOVERNMENT OF WEST BENGAL

HEALTH & FAMILY WELFARE DEPARTMENT
NATIONAL HEALTH MISSION (NHM)
GN -29, 2nd FLOOR, GRANTHAGAR BHAWAN,
SWASTHYA BHAWAN PREMISES, SECTOR-V
SALT LAKE, BIDHANNAGAR, KOLKATA - 700 091.
0033 - 2333-0432,0 033 - 2357 - 7930,
Email ID: spmu.nuhm@gmai1.com; website: www.wbhealth.gov.in

Memo No. HFW/NUHM-685/2015/ 12:r S'8 25/05/2018

From: Addl. Mission Director, NHM

Government of West Bengal
To : Chief Municipal Health Officer,
Kolkata Municipal Corporation (KMC)

Sub: Formats for Registers & OPD Ticket for U-PHC, NUHM

Sir,
Standard format for Registers. OPD Tickets & Referral slips for use in
UPHCs under NUHM are approved by competent authority.
You are requested to introduce these formats at UPHCs under NUHM at
KMC.
Standard formats are enclosed as Annexure I to VII.

Yours faithfully,
A fV"~.t..~
ADDITIONAL MISSION DIRECTOR

Memo No. HFW/NUHM-685/2015/ 2:;52/ I [~ 25/05/2018

Copy forwarded for information and necessary action to:

1. The Nodal Officer, Kolkata City NUHM Society, West Bengal
2. IT Cell for web posting
4A~
ADDITIONAL MISSION DIRECTOR
 21/22
155782/2018/NHM SEC(H&FW)

…………………………………………………………...……………………………………Laboratory Register…………………………………………………………………………………..Month

Sex Time and

RSBY/Swasthya Date and
Serial Registration Age (yrs, (Male/ Sample ID Date of Tested by
Date Name of Patient Residence Sathi card holder Tests advised Test results signature of
number number months) Female/O Number receiving method
Yes/No MT (Lab)
thers) sample
 19/22
155689/2018/NHM SEC(H&FW)

…………………………………………………………...……………………………………OPD Register…………………………………………………………………………………..Month

Whether referred
Sex (Male/ RSBY/Swasthya
Serial Registration Age (yrs, Provisional Laboratory test Yes/No, if yes Reasons for
Date Name of Patient Old New Residence Female/ Sathi card holder
number number months) diagnosis advised then where referral
Others) Yes/No
referred
 15/22
153977/2018/NHM SEC(H&FW)

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Municipal Corporation Logo of Municipality I
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\ NATIONAL URB.AN
Health Department
\HEAlTH MISSION
t:::::::::: __ / Ticket for Outdoor Patient

Ward No.......... UPHC NO.................. Registration No .

Date .

Patient Details:

Name : ••••..••.••.•••••.•••••••••.•••.•.•••••••.••.••.•••.••.••..•.••..••..
, Age .•••••..•...•..•.
Sex . .
Address:
, .
Height ,.•••••••••.••••
Weight •.•.•.••...•..••.. BP ,•••••••••••••••••

Diagnosis .••.••.•••••..•.••••••.••..•••.••.•......•...•.....••..••.••.••..••.....••.•••..•....•.....••.••..•..•..•••.•••..••••••..•••••••••..••.•••.••••.•
Date
Treatment

/
 13/22
153977/2018/NHM SEC(H&FW)

SERVICE CLINIC REGISTER (Child Health & Immunization))

NAME OF MUNICIPALITY: NAME OF U-PHC : WARD / BLOCK:

CAST
NAME OF
a: Date E
Sl. RCH CLIENTwith w
ADDRESS c of (SC/S
NO. portallD GUARDIAN's z
w
l!) Birth T/BPl
NAME
)
 12/22
153977/2018/NHM SEC(H&FW)

SERVICE CliNIC REGISTER (Maternal Health& FW Service)

NAME OF MUNICIPALITY: NAME OF U-PHC : WARD / BLOCK:

CliENTDE~ FW~ice ANTENATAL~ARE

~ ~
NAME OF
CLIENT with
CASTE
No. of
OP/CC/
IUD-37S,
PRE ANC
I I
«
c e
c?;
0
c: WBFPT
'* Cl:'
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bIl
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SIGNS INJ. Place of Mode
Number

SL.
RCH
portal
GUARDIAN's
NAME
ADDRESS AGE
c:
0
:§
(SC/ST
/BPL)
Living
childr
Date of
last
380A/
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G.
1 TEST
VISIT
(1/2/
s
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for
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(1~t/2nd/
OF
'HIGH
DEXAMET
HASONE
delivery
(Home/Tr
of
deliver
of visit &
Maternal
death
IFA
NO. (Husband in Qi en child tchrorna <,
W ::> 0 VI .c ;::: 'iii c: RISK (for pre- ansit/lnsti y (Home I
10
case of
0:: &JSY
with birth n
(+/ 3/4/ « 3: "0
0 E (R/ NR) (Pos/ E "0
0 !!. 0:: U CIJ
.c Booster)
PREGN term tution -
Ion (if
Transit)
~
entry. ) )
0::
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0
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CIJ

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(Norma
any)
married
woman)
age
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a:
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ANCY. delivery) Pub/Pvt) 1/ CS) .:'

L_
L_
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->

,
 14/22
153977/2018/NHM SEC(H&FW)

SERVICE CLINIC REGISTER (Public Health)

NAME OF MUNICIPALITY : NAME OF U-PHC : WARD / BLOCK:

CLIENT DETAil VECTOR BORNE DISEASES Other Diseases

I-
z
w
~
iii I-
> <!
w
"'
e
c:
c:::
l-

Sl.
NAME OF CLIENT -....
Q) MALARIA BLOOD RDK-
Referre
d for
1. Diarrhoea
tract infection
2. Respiratory
3. Fever with
011
C)
z
> REMARKS

-
with GUARDIAN's ADDRESS Q) Treatment ::::i
NO. LI.. SLIDETAKEN/ RDT MALARIA RDK ( rash 4. Fever with Head ache, DOTS provided for Tuberculosis / leprosy ...J
w
NAME DONE given 11'1
0 (+/ -) KA) Body ache, Joint Pain S.Other z
c: ::l
0
.,0:;
Test Minor Ailments (Specify) 0
,
u
"'
....

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::::I i=
e c:::
i=
11'1
 11/22
153977/2018/NHM SEC(H&FW)

Card No. (REFERRAL CARD FOR NUHM FOR REFERRED OUTPATIENTS)

""
"

Referred from: '" (Please mentioned name of facility)

Referred to: ... ... ... ... ... ... ... ... ... ... ... (Please mentioned name of facility)

Name of patients: '" .

Address: ..
Age: .

Sex: Male o Female 0 (put v marks in.box] 0 O~~.

Nature of disease or illness: .

Provisional diagnosis: '"

Reason for referral: . Date & time of referral: .

Treatment given: (please enclosed sheet if required) ..

Referred by:

Name Designation Signature with date

 18/22
155662/2018/NHM SEC(H&FW)

REFERRAL register

Name of
Sex Description of
Registration Cause of Date and Time referring
Sl.No. Date Name & Address Age (M/F/ Diagnosis Referred To treatment Remarks
No. Referral of Referral Medical
Others) given
Officer
 20/22
155714/2018/NHM SEC(H&FW)

…………………………………………………………...……………………………………Stock Register…………………………………………………………………………………..Month

Received
Form(Tablet/Syrup/I from
njectables/ which Quantity Signature of
Description Batch VVM Opening Quantity Issued to Balance in
Date Item number Vaccine/Vial/ stores Expiry date received Store in
of item number status Balance issued whom stock
Ampoule/Infusion (mention charge
etc) IV/RV
number)