For Office Use Only
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:
______________________________________________________________________________________