Pregnant Woman Basic Information: Mcts Format - I

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MCTS FORMAT - I

Pregnant Woman Basic Information


Major Component

Location Details

Sl.#

Sub Component

Data

District

Deogarh

Block

Name of Sub-Centre

Village

Nilabeni Sah

Name

ANITA PATRA

Husband's name

Address

PPC
Ward No-9

MAHENDRA PAT

Ward No-9, Nilabe

7.1 Bank Account No


7.2 Adhaar Card No.

Identification Details

Phone Number of Whom

Phone Number with STD Code

10

LMP (dd/mm/yyyy)

11

Date of Birth (dd/mm/yyyy) / Age

12

Caste (Put a mark)

Other

9668669088
5/22/2014

SC

12.1 Economic Status


13

JSY Beneficiary (Put a mark)


Status

14

Health Provider
Details

Mother Tracking Format

Service

If Migration In, Please Provide detail


address

15

No of living Childern with


Age of Last Child

16

Name of ANM

17

Phone Number of ANM

18

Name of ASHA

19

Phone Number of ASHA

20

Linked facility for delivery


(Put a mark)

ST

| Oth

BPL
YES

NO

StateDistBlockSCVillG1

Annada Shankar A

9668669088

SC | CHC

| PHC

SDH | MCH | Pvt.Hos

21

Name of Facility for Delivery

Deogarh DHH

22

1st ANC Date (dd/mm/yyyy)

8/2/2014

23

TT 1 (dd/mm/yyyy)
M E Cell, NRHM

Service

24

TT -2 /TT-Booster (dd/mm/yyyy)

25

Anemia(HB Level)

Normal | Modorate<11

Hypertensive | Diabet
26

Complications
Malaria | Other |

27

Mother Tracking Format

RTI/STI

YES

M E Cell, NRHM

NO

Data

eogarh
PPC

ard No-9

beni Sahi

TA PATRA

NDRA PATRA

9, Nilabeni Sahi

Other

8669088

22/2014
19
| Others
APL

hankar Achrya

8669088

| PHC | DHH
Pvt.Hosp | Other

garh DHH

2/2014

Mother Tracking Format

M E Cell, NRHM

orate<11 | Sever<7
| Diabetics | APH

| Other | None
|

NO

Mother Tracking Format

M E Cell, NRHM

MCTS FORMAT - I
Pregnant Woman Basic Information
Major Component

Location Details

Sl.#

Sub Component

Data

District

Deogarh

Block

Name of Sub-Centre

Ward No-3

Village

Matha Sahi

Name

Husband's name

Address

PPC

MANINI PRADH

SAROJ KUMAR N

Ward No-3, Matha

7.1 Bank Account No


7.2 Adhaar Card No.

Identification Details

Phone Number of Whom

Phone Number with STD Code

10

LMP (dd/mm/yyyy)

11

Date of Birth (dd/mm/yyyy) / Age

12

Caste (Put a mark)

Self

9583226782
5/6/2014

SC

12.1 Economic Status


13

JSY Beneficiary (Put a mark)


Status

14

Health Provider
Details

Mother Tracking Format

Service

If Migration In, Please Provide detail


address

15

No of living Childern with


Age of Last Child

16

Name of ANM

17

Phone Number of ANM

18

Name of ASHA

19

Phone Number of ASHA

20

Linked facility for delivery


(Put a mark)

ST

| Oth

BPL
YES

NO

StateDistBlockSCVillG1

Annada Shankar A

9668669088

SC | CHC

| PHC

SDH | MCH | Pvt.Hos

21

Name of Facility for Delivery

Deogarh DHH

22

1st ANC Date (dd/mm/yyyy)

8/2/2014

23

TT 1 (dd/mm/yyyy)
M E Cell, NRHM

Service

24

TT -2 /TT-Booster (dd/mm/yyyy)

25

Anemia(HB Level)

Normal | Modorate<11

Hypertensive | Diabet
26

Complications
Malaria | Other |

27

Mother Tracking Format

RTI/STI

YES

M E Cell, NRHM

NO

Data

eogarh
PPC

ard No-3

tha Sahi

NI PRADHAN

UMAR NAYAK

3, Matha Sahi

Self

3226782

6/2014
21
| Others
APL

hankar Achrya

8669088

| PHC | DHH
Pvt.Hosp | Other

garh DHH

2/2014

Mother Tracking Format

M E Cell, NRHM

orate<11 | Sever<7
| Diabetics | APH

| Other | None
|

NO

Mother Tracking Format

M E Cell, NRHM

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