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Date: / / Date: / /
Date of birth: / / (or) Age: Social Grp: Date of birth: / / (or) Age: Social Grp:
A: A:
TB history: No Yes DOTS: Non-DOTS: TB history: No Yes DOTS: Non-DOTS:
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