Form Preview

Form Id: SCR_TB


Screening (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