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REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME
Referral / Transferform for treatment
Serial Number
To be filled
in
triplicate. One copy to be sent to the DTO receiving the patient, one copy to the health
facility where the patient is referred to, and one copy to the patient
Name and address of referring health facility ___________________________________________________
Contact Number and e-mail address of referring health facility: ___________________________________
Name and address of health facility to which patient is referred ___________________________________
__________________________________________________________________________________________
Name of patient__________________
Age________________ Sex M F TG
Complete Address
__________________________________________________________________________
___________________________________________________________Contact no.____________________
Patient detail
Site of disease
Pulmonary
Extra Pulmonary, Site ______________
Type of Patient
New Recurrent
Transfer in Treatment After Failure
Treatment
Others, previously treated
After LFU (Specify)________
Basis of Diagnosis
Microbiologically confirmed
Clinical TB
H/O of ATT:
___ months of treatment
___ months since end of last episode
Diagnosis details
Date of diagnosis: __/__/___
Name of laboratory:
Type of test: ZN / FM / CBNAAT / Culture
Result : _________________________
TB notification number:____________
HIV Status:
R NR Unknown
DST Status:
Rif Sensitive
Rif Resistant
Unknown, if unknown
Sample sent for DST to ______________
Date: __/__/__
Treatment regimen:
New Previously Treated
Date of treatment initiation: : __/__/__
Number of doses:_____________________
Referred for:
Initiation of treatment
Adverse drug reaction (give details) ___________________________________________________
Transfer out (give details)___________________________________________________________
Any other (give details)_____________________________________________________________
Name and designation of the referring doctor______________________________________________________
Date referred
------------------ ------------------------------------------------------------------ --------------------------------------
Serial Number____________________
For use by the health facility where the patient has been referred
Name of receiving health facility
Name of TB Unit and District_________
Name of patient __________________
TB No (if available)_______________________
Age___________________ Sex M F Date of receipt of patient_______________________________
Date of initiation of treatment ___________________________Treatment regimen_____ __________________
Result of End IP specimen examination ______________ Date of end IP specimen examination __________
Treatment outcome ________________________________Date of treatment outcome ____________________
Signature_______________________Designation_______________________________Date_______________
This portion of the form has to be sent back to the referring unit as soon as the patient has
been initiated on RNTCP treatment
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Annexure 15 G