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C.lab Request and Report Form

This document is a request form for the examination of a biological specimen for tuberculosis (TB). It includes patient information, previous treatment history, specimen type, and requested tests, along with sections for laboratory results. The form requires signatures from the requesting and examining personnel, along with dates for tracking purposes.

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shein zaw
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26 views1 page

C.lab Request and Report Form

This document is a request form for the examination of a biological specimen for tuberculosis (TB). It includes patient information, previous treatment history, specimen type, and requested tests, along with sections for laboratory results. The form requires signatures from the requesting and examining personnel, along with dates for tracking purposes.

Uploaded by

shein zaw
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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Request for examination of biological specimen for TB

Referred/ Treatment unit: ________________________________ Date of request: __________________________


Patient’s name: ________________________________________
Age (years): _______ Date of birth: _____________________ Sex: Male Female
Patient’s address: ________________________________________________________________________________
______________________________________________ Telephone: _____________________________________
Previously treated for TB: Yes No Unknown
if Yes: Took full course? Yes No Unknown
DM status: Yes No Unknown
HIV Status: Positive Negative Unknown
Reason for examination: _________________
Diagnosis Presumptive TB Reg. / OPD No._________ TB No.______________
Follow-up Township TB No/MDR-TB No._____________ Month of treatment_________
Specimen type: Sputum Other (specify):_______________________
Test(s) requested: Microscopy Truenat MTB/RIF
Requested by Signature: ________________
Name: ________________
Designation: ________________
Contact phone no. : ________________
__________________________________________________________________________________________

Microscopy results (to be completed in laboratory) ZN


Visual appearance Result (tick one)
Date of Laboratory
Specimen (blood-stained,
specimen serial
type mucopurulent or Negative Scanty + ++ +++
received number(s)
saliva )

Examined by Signature: ________________


Name: ________________
Designation: ________________
Date of result: ________________
__________________________________________________________________________________________
Trunat MTB/RIF test result (to be completed in the laboratory)
Date of specimen collected: ____________________ Lab No : ____________________
MTB Valid Valid Invalid Error
result detected Not detected
Rif resistant Detected Not detected Intermediate Error
result

Examined by Signature: ______________________


Name: ______________________
Designation: ______________________
Date of result: ______________________
______________________________________________________________________________________

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