MASS SCREENING FORM MASS SCREENING FORM
Date: / / Date: / /
Full name: Full name:
Date of birth: / / (or) Age: Social Grp: Date of birth: / / (or) Age: Social Grp:
Weight: kg Height: m BMI: kg/m2 Weight: kg Height: m BMI: kg/m2
Blood Pressure: / mmHg Blood Pressure: / mmHg
A: A:
TB history: No Yes DOTS: Non-DOTS: TB history: No Yes DOTS: Non-DOTS:
TB treatment: No Yes Complete: Incomplete: TB treatment: No Yes Complete: Incomplete:
TB exposure: No Yes TB exposure:No Yes
(In the past 2 years) (In the past 2 years)
NO YES DURATION NO YES DURATION
B: B:
Productive cough: <1 week >1 week Productive cough: <1 week >1 week
Blood expectoration: Blood expectoration:
C: C:
Weight & appetite loss: Weight & appetite loss:
Persistent fever: Persistent fever:
Night sweating: Night sweating:
Chest pain/breathing difficulty: Chest pain/breathing dificulty:
D: D:
Medical Condition / Risky Behavior Year /Medication Taken Medical Condition / Risky Behavior Year /Medication Taken
Hypertension Hypertension
Diabetes Mellitus Diabetes Mellitus
Asthma Asthma
Smoking (currently) Smoking (currently)
Other conditions/complaints Other conditions/complaints
Health Interviewer: Health Interviewer:
Name & Signature Name & Signature
E: E:
X-ray screening: Clear: TB suggestive: Undetermined: X-ray screening: Clear: TB suggestive: Undetermined:
Results: Results:
1 Presumptive TB are(one or combination of the following criteria) 1 Presumptive TB are: (one or combination of the following criteria)
Productive cough of any duration and/or haemoptysis Productive cough of any duration and/or haemoptysis
Suggestive chest X-Ray (CXR) Suggestive chest X-Ray (CXR)
Undertermined CXR + any of other parameters (A, B, C & D) or low BMI Undertermined CXR + any of other parameters (A, B, C & D) or low BMI
Any of C elements in combination or in parallel with low BMI or other parameters Any of C elements in combination or in parallel with low BMI or other parameters
2 Presumptive DR-TB are: 2 Presumptive DR-TB are:
TB suspects with previous TB history TB suspects with previous TB history
TB suspects even without previous history in a conglomerete setting with DR-TB TB suspects even without previous history in a conglomerete setting with DR-TB
3 No TB suspicion: Clear CXR and lack of any other parameters & low BMI 3 No TB suspicion: Clear CXR and lack of any other parameters & low BMI
Remarks: Remarks:
NOT NOT
PRESUMPTIVE PRESUMPTIVE PRESUMPTIVE PRESUMPTIVE
FOLLOW-UP PRESUMPTIV FOLLOW-UP PRESUMPTIVE
TB DRTB TB DRTB
E TB TB
Heath Validator: Health Validator:
Name & signature Name & signature