Form 4. TX Ipt Card v061416

Form 4.
TB Treatment/ IPT Card

TB CASE No./ IPT No.: DATE OF REGISTRATION: REGION & PROVINCE/ CITY: NAME OF DOTS FACILITY:
(MM/DD/YY)
NAME OF PATIENT (SURNAME/ First Name/ Middle Name): Date of Birth (MM/DD/YY): Age: Sex: Height: BCG Scar:
______ /______/_______ ______ years ______ mos. ______ cm. [ ]Yes [ ]No [ ]Doubtful
COMPLETE ADDRESS & CONTACT NO.: Other Patient Details: HOUSEHOLD MEMBERS:
Occupation: _____________________________________ First Name Age Date Screened
SOURCE OF PATIENT: Philhealth No.: ___________________________________
[ ] Public Health Center [ ] Community
[ ] Other Government Facilities/ Hospitals Contact Person: __________________________________
[ ] Private Hospitals/ Clinics/ Physicians/ NGOs Contact No.: _____________________________________
DIAGNOSTIC TESTS: HISTORY OF ANTI-TB DRUG INTAKE: [ ] No [ ] Yes When:
1. Tuberculin Skin Testing (TST): 2. CXR Findings: Duration: [ ] less than 1 mo. [ ] 1 mo. or more
Result: _____mm ____________________ Drugs taken: [ ]H [ ]R [ ]Z [ ]E [ ]S
Date Read: _____/_____/_____ Date of Exam: _____/_____/_____ BACTERIOLOGICAL STATUS: TB DISEASE TREATMENT REGIMEN (encircle)
3. Other Exam: __________________ TBDC : __________________ [ ] Bacteriologically Confirmed I. 2HRZE*/4HR II. 2HRZES/1HRZE/5HRE
Date of Exam: _____/_____/_____ [ ] Clinically Diagnosed 1. PTB, New-bacteriologically confirmed 1. Relapse
4. Xpert MTB/RIF Result: _________ Date Collected:___/ ____/ ____ ANATOMICAL SITE: 2. PTB, New-clinically diagnosed 2. Treatment After Failure
5. DSSM Results: [ ] Pulmonary [ ] Extra-pulmonary 3. EPTB, New 3. TALF
Month Due Date Date Examined Result specify: ____________ 4. Previous Treatment Outcome
0 REGISTRATION GROUP: Unknown
2 [ ] New [ ] Treatment After LTFU Ia. 2HRZE*/10HR
3 [ ] Relapse [ ] PTOU 1. EPTB, New-CNS/ bones or joint IIa. 2HRZES/1HRZE/9HRE
4 [ ] Treatment After Failure [ ] Other 1. EPTB, Retx-CNS/bones or joint
5 [ ] Transfer-in *For children <4 weeks, change E to S
6 DATE TREATMENT/ IPT STARTED:
>7
6. PICT done? [ ]Yes [ ]No (MM/DD/YY)
DIAGNOSIS: [ ] TB DISEASE TREATMENT OUTCOME: Date of Last Intake" (MM/DD/YY) ___________________________

[ ] CURED [ ] FAILED
[ ] TB INFECTION, for IPT (for children below 5 y/o) [ ] TREATMENT COMPLETED [ ] LOST TO FOLLOW-UP, specify reason: ___________________
[ ] TB EXPOSURE, for IPT (for children below 5 y/o) [ ] DIED, specify cause of death:_________________ [ ] NOT EVALUATED [ ] EXCLUDED FROM COHORT
CLINICAL EXAMINATION BEFORE AND DURING TREATMENT: [/] if present, [O] if absent, [--] if not applicable or write specific sign or symptoms
Initial 1 2 3 4 5 6 7 8 9 10
Date Examined/ Results
___/___/___ ___/___/___ ___/___/______/___/______/___/______/___/______/___/______/___/___
___/___/______/___/______/___/___
Weight in Kg.
Unexplained fever >2 wks
Unexplained cough/ wheezing >2wks
Unimproved general well being*
Poor appetite
Positive PE findings for Extra-pulmonary TB
Side Effects**
* 1-fatigue, 2-reduced playfulness, 3-lethargy ** 1-itchiness, 2-skin rashes, 3-vomiting, 4-abdominal pain, 5-joint pains, 6-numbness, 7-yellowing of sclerae and skin, 8-visual disturbance, 9-hearing disturbance, 10-others
DRUGS: Dosages and Preparations (for children)

Isoniazid [H] 10mg/kg (200mg/5ml) _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml
Rifampicin [R] 15mg/kg (200mg/5ml) _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml
Pyrazinamide [Z] 30mg/kg (250mg/5ml) _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml
Ethambutol [E] 20mg/kg (400mg tab) _____tab _____tab _____tab _____tab _____tab _____tab _____tab _____tab _____tab _____tab _____tab _____tab
Streptomycin [S] 15mg/kg (1g/vial) _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml _____ml v.ntpmo/061416
Name of Treatment Partner: ____________________________ Designation of Treatment Partner: _________________
Drug Intake (Intensive Phase/6 months IPT): initials if supervised by treatment partner, [--] if self-administered, 0 if absent
Doses given
Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 for this Total doses given
month
Drug Intake (Continuation Phase): initials if supervised by treatment partner, [--] if self-administered, 0 if absent
Doses given
Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 for this Total doses given
month
Remarks: ______________________________________________________________________________________________________
______________________________________________________________________________________________________________
v.ntpmo/061416
______________________________________________________________________________________________________________

Form 4. TX Ipt Card v061416

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Form 4. TX Ipt Card v061416

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Form 4.

TB Treatment/ IPT Card

DIAGNOSIS: [ ] TB DISEASE TREATMENT OUTCOME: Date of Last Intake" (MM/DD/YY) ___________________________

DRUGS: Dosages and Preparations (for children)

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