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Request Form Ujian Tibi IMR

This document is a request form for tuberculosis testing at the Infectious Diseases Research Centre. It collects patient information, clinical summary, medical history, and specimen information necessary for laboratory testing. The form is designed for use by healthcare professionals to facilitate the diagnosis and treatment of tuberculosis.

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kulimmedical
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109 views1 page

Request Form Ujian Tibi IMR

This document is a request form for tuberculosis testing at the Infectious Diseases Research Centre. It collects patient information, clinical summary, medical history, and specimen information necessary for laboratory testing. The form is designed for use by healthcare professionals to facilitate the diagnosis and treatment of tuberculosis.

Uploaded by

kulimmedical
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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BACTERIOLOGY UNIT IMR/IDRC/BACT/TB/01

INFECTIOUS DISEASES RESEARCH CENTRE (IDRC)


INSTITUTE FOR MEDICAL RESEARCH (IMR)
NATIONAL INSTITUTES OF HEALTH (NIH)
NO 1, JALAN SETIA MURNI U13/52, SEKSYEN U13, SETIA ALAM, 40170, TUBERCULOSIS LABORATORY
SHAH ALAM, SELANGOR REQUEST FORM
Tel: 03-3362 8360 EMAIL: [email protected]

PATIENT’S INFORMATION
Name: Age: DOB: __ /__ /____

Identification card (IC)/ Passport No : R/N : Gender:  M  F


Ethnicity:  Malay  Chinese  Indian  Others (please specifiy): ______ Nationality:  Malaysian  Non-Malaysian: ____________
Address:
Date of admission: Patient’s Occupation:
Hospital: Ward/ Clinic:
Name and stamp of
Signature of Dr:
requesting Doctor:

CLINICAL SUMMARY

Diagnosis: Duration of illness:


Pulmonary TB Extrapulmonary TB
 Fever, duration: ______  Loss of appetite  Headache  TB CNS, specifiy
 Cough,  Loss of weight  Weakness  TB Skin, specifiy
 Shortness of breath  Lymphadenopathy  Dizziness  TB Bones & Joints, specifiy
 Haemoptysis  Others: _________________  Altered behaviour  TB GIT, specifiy
 Night sweats __________________________  Myalgia  TB Genitourinary, specifiy
 Chills & Rigors: __________________________  Arthralgia  Others: _________________

MEDICAL AND TB HISTORY

 BCG vaccination  Diabetes mellitus


 Previous TB infection: Year ( )_______  Hypertension

 TB treatment : ongoing / completed / not completed  Chronic kidney disease


 AFB Smear: Positive (scanty / 1+/ 2+/3+) x ( )  HIV / IVDU
 Mantoux: Positive ( mm) / Negative  Autoimmune disease
 Contact with TB patient: Yes / No  Malignancy
 Healthcare worker  Others

 Chest X-ray:  Smoking

 Others
SPECIMEN INFORMATION LABORATORY INFORMATION
Type of specimen:  Sputum  Skin
 Pulmonary samples: BAL, Tracheal aspirate,  Stool
Gastric lavage, Pleural fluid, Synovial fluid  Formalin-Fixed Paraffin-Embedded Date of test performed: __ / __ / ____
 Tissue, specifiy ____________________ (FFPE) tissue
 Pus, specifiy _______________________  Others, specifiy ______________________
 CSF
Result of test:
 Other body fluid: Pericardial fluid,
Peritoneal fluid, Ascitic fluid, Urine, Blood

Version : 4.0 Date Issued: 12th January 2023 Approved by: Head of Bacteriology Unit
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