Form Id: SCR_TB
ENGLISH FRANÇAIS PORTUGUÊS ITALIANOScreening (positive if only one of the following 5 symptoms is positive) | |
| Cough: | |
| Fever: | |
| Night sweats: | |
| Weight loss: | |
| Lethargy/ Reduced Playfulness? (only for <15): | |
| Failure to Thrive? (only for <15): | |
| Chest Pain: | |
| History of Contact with a person with TB: | |
| TB Screening Score: | RESULT: SCORE |
| TB Screening Result: (automatic evaluation not working in preview) | |
Indicate Action Taken | |
| Sputum Smear Ordered: | |
| Sputum Smear Result: | |
| Chest Xray Ordered: | |
| Chest Xray Result: | |
| GeneXpert Ordered: | |
| GeneXpert Result: | |
| Clinical diagnosis: | |
| Invitation of contacts: | |
| Resulting TB Status: | |
| Evaluated for TPT: | |
| Start Anti-TBs: | |
| Anti-TBs Start Date: | |
| Facility where patient started on TB treatment: | |
TPT FollowUp | |
| TPT Due Date: | |
| Weight: | |
| Hepatotoxicity?: | |
| Peripheral Neuropathy?: | |
| Does the patient have Rash?: | |
| Others? (e.g. gastrointestinal disturbances): | |
| Adherence Measurement: | |
| Action Taken: | |
Note: This is just a preview: not all features are guaranteed
