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National TB Control Program Form 7 - Referral Form

This document is a referral form used by the Philippines National TB Control Program (NTP) for referring tuberculosis (TB) patients between treatment facilities. It collects key patient information like name, age, sex, treatment history and reason for referral. Reasons include evaluation for drug-resistant TB, continuing treatment, or starting preventive therapy. The form aims to facilitate evaluation and proper management of TB patients moving between treatment sites.

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2K views

National TB Control Program Form 7 - Referral Form

This document is a referral form used by the Philippines National TB Control Program (NTP) for referring tuberculosis (TB) patients between treatment facilities. It collects key patient information like name, age, sex, treatment history and reason for referral. Reasons include evaluation for drug-resistant TB, continuing treatment, or starting preventive therapy. The form aims to facilitate evaluation and proper management of TB patients moving between treatment sites.

Uploaded by

Are Pee Etc
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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National TB Control Program (NTP)

Programmatic Management of Drug-resistant Tuberculosis (PMDT)

Form 7. NTP Referral Form


TB Case Number
To: Date Referred:
Please accommodate the patient bearing this referral form. Kindly inform the Referring DOTS Staff as soon as patient has been evaluated by calling, sending SMS/email or
sending back the Return Slip below.
(To be accomplished by Referring Unit)
Name of Referring Unit Telephone No. Fax No. E-mail Add.

Address of Referring Unit

Full Name of Patient (SURNAME, Given Name, Middle Name) Age Sex Weight (kg)

Patient's Address

Reason for Referral:


[ ] For DSSM [ ] For evaluation of Presumptive DRTB (Write history below)
[ ] For registration and treatment (Write regimen below) O Relapse O HH Contact of DRTB Case
[ ] For continuation of treatment/ transfer-out (Write regimen below) O Treatment After Failure O Non-converter of Cat I or II
[ ] For IPT (children 0-4 y/o) O Treatment After Lost to Follow-up O PLHIV with TB symptoms
O Previous Treatment Outcome Unknown O Other

_____________________________________________________________________________________
[ ] Others, specify
Details: History of TB Treatment or Recommended Regimen and Other Pertinent Information
Date Treatment Started-Treatment Unit-Anti-TB Drugs and Duration-Outcome (earliest to latest) or Drug-Preparation-No of Units/Day

Name of Referring DOTS Staff Signature Cellphone No./ Email Add. Designation

Please attach copy of: 1. NTP Treatment Card/s of Previous Treatment/s, 2. Latest DSSM results, 3. Other laboratory results (CXR, TBDC, blood chem.)

Return Slip
Name of Referring Unit:
Address of Referring Unit:
(To be accomplished by Receiving Unit)
Name of Receiving Unit Date Received Contact No.

Full Address of Receiving Unit

Name of Patient

Name of Receiving DOTS Staff Signature Cellphone No./ Email Add. Designation

Action Taken:
[ ] DSSM performed, write date ____/ ____/ ____ and results ______________________________
[ ] Patient started/ resumed treatment and registered: TB Case No._______________ Date Registered/ Resumed ____/ ____/ ____
[ ] Evaluated as Presumptive DR-TB, Xpert test performed write date ____/ ____/ ____ and results _________________________
[ ] Not enrolled, specify reasons/s _______________________________________________________________________________________________
[ ] Others, specify ____________________________________________________________________________________________________________
Remarks:

_____________________________________________________________________________________________________________

Form 7. NTP Referral Page 1 of 1 v.011817

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