For Office Use Only         

                                                                                         Lab. Ref.  No. ______________

Particulars of the Patient:                                                                      

Name ____________________________________________   Age ________ Sex _______ Wt ______

Address____________________________________________________________________________________________

Registration No. _____________________________      Referred by ___________________________________________

Provisional Diagnosis  _________________________________________________________________________________

A. Clinical History & Findings                                                                     If yes; Duration

Cough                                                                        Yes / No         ___________________________

Haemoptysis                                                              Yes / No         ___________________________

Fever                                                                         Yes / No         ___________________________

Breathlessness                                                          Yes / No        ___________________________

Loss of weight                                                             Yes / No        ___________________________

Chest pain                                                                  Yes / No        ___________________________

Loss of appetite                                                           Yes / No        ___________________________

Headache                                                                   Yes / No        ___________________________

Vomiting                                                                     Yes / No        ___________________________

Convulsion                                                                  Yes / No        ___________________________

Pain abdomen                                                             Yes / No        ___________________________

Swelling abdomen                                                        Yes / No        ___________________________

Joint Pain/swelling                                                       Yes / No        ___________________________

Infertility                                                                      Yes / No        ___________________________

Haematuria                                                                  Yes / No        ___________________________

Other, if any                                                                 Yes / No       ___________________________

______________________________________________________________________________________

B. Antituberculosis Treatment History:

1.  Fress Case                Yes / No                If yes, since

2.  Relapse Case            Yes / No                Duration

______________________________________________________________________________________

C. Radiological Impression :

______________________________________________________________________________________

D. Bacteriological Status:                                            Done / Not done  

Sputum                                                                  Fluid CSF/Synovial/Pleural/Peritonial Fluid)

AFB smear   + ve / - ve                                             AFB smear   + ve / - ve

AFB culture + ve / - ve                                              AFB culture + ve / - ve            

                                                                              Protein ______________      

                                                                             Sugar ______________        

                                                                             M / E ______________                                   

______________________________________________________________________________________

E. Histopathological Impression:

______________________________________________________________________________________

 F. Fine Needle Aspiration Cytological (FNAC) Impression :

______________________________________________________________________________________

 Any other relevant information:

______________________________________________________________________________________

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