Dengue Survey Report
Gram Panchayat
Select Gram Panchayat ---
Bodra
Chandaneshwar-I
Chandaneshwar-II
Durgapur
Jagulgachi
Narayanpur
Pranganj
Shanksahar
Tarda
Mouza
Select Mouza ---
Polling Station
Select Polling Station ---
Village/ Para
House ID
Name of the Patient
Father/ Husband Name
Age of the Patient
⚧️Gender
Select Gender....
Male
Female
Third Gender
📱Mobile No.
Normally where resides (in house/ out side house)
Place of residing when detected
Occupation of the patient/ family
Date of examination
Date of Symptom
Date of Result of investigation
Presently where residing ?
Age & Gender wise family members' information
Details of any other family member(s) regarding fever or any other disease
Details of any other people in the neighbour regarding fever or any other disease
Whether all the families in the locality use Mosquito Net
Select Status....
Yes
No
Use Other types of repealnat
Whether Larvae containg pot or potential pot for larvae found
Select Status....
Yes
No
Partly
Action Taken Report
📅Date of Inquiry
📷
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