National TB Control Program (NTP)

DR-TB Screening Form

Screening Center: PAETE RHU IDOTS Screening Code Date:

Name Type Region TC-YY-MM-NNNN MM/DD/YY

I. Demographics
Full Name: Age: Sex:
SURNAME, Given Name Middle Name

Date of Birth: Civil Status: Religion:

MM/DD/YY

Nationality: FILIPINO Number of Household Contacts: Total ≥ 15 y/o < 15 y/o

Permanent Address:
House Number Street Village Barangay City/ Municipality Province Region Zip Code

Current Address:
House Number Street Village Barangay City/ Municipality Province Region Zip Code

Landline: Mobile Number:

Occupation: E-mail Address:

Person to notify in case of emergency: Relationship:

Address: Contact Number:

Referred by: Address:

Name Type of Facility (HC, Govt. Institution, PPMD, NGO, Pvt MD/ Inst) Municipality/ City Province Region

------------------------------ --------------------------- to be filled up by staff of screening facility ------------------------------ -------------------------

II. Review of Symptom/s & Past Medical History

Duration & Comments Date/ Duration &/or Comments

[ ] Cough [ ] Co-Morbidities
[ ] Fever
[ ] Back/ Chest Pain [ ] Allergies
[ ] Hemoptysis
[ ] Weight Loss [ ] Concomitant Drugs
[ ] Night Sweats
Others: [ ] Previous Surgery

History of TB Treatment Date Treatment Started Treatment Unit Anti-TB Drugs and Duration Outcome
1earliest
2
3
4
5 latest

Exposure to active TB? [ ] No [ ] Yes Details:

[ ] DSTB [ ] DRTB [ ] Unknown

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 National TB Control Program (NTP)

III. Social and Sexual History (cigarettes, alcohol, drug abuse,'sexual hx, pregnancy, etc.) IV. Physical Examination and Laboratory Procedures:
System Examination: Describe Abnormalities

0
Height: cm Temperature: C PR/ HR: RR at Rest: /min
Weight: kg Blood Pressure: mmHg 02 Sat by Pulse Oximeter: %

DSSM, TBC or DST from Other Lab: [ ] copy attached Other Lab Results: [ ] copy attached
Laboratory Test Date Result Laboratory Test Date Result

Chest X-Ray: Date: Impression:

[ ] copy attached

V. Assessment
Presumptive DRTB Case: [ ]Y [ ]N Other disease:

Registration Group: Site: Risk Factors:

[ ] New [ ] Pulmonary [ ] None
[ ] Retreatment [ ] Extra-pulmonary [ ] Contact of a confirmed/ suspected DRTB case with CXR
[ ] Relapse specify, findings/ symptoms suggestive of TB
[ ] Treatment after Failure [ ] Non-converter of Category I or Category II treatment
[ ] Treatment after Lost to Follow-up [ ] PLHIV with signs and symptoms suggestive of TB
[ ] Previous Treatment Outcome Unknown
[ ] Other

VI. Plan
[ ] For Xpert MTB/RIF

[ ] Refer (back) to for

Name of Facility Recommendation

[ ] Others:

Screened by: Date:

Attending Physician: Donne Randolf M. Framil, MD, MPH Date:
/
[ ] Paunawa Administered

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