NATIONAL SURVEY OF TUBERCULOSIS DRUG RESISTANCE KWAZULU NATAL TB SUSPECT IDENTIFICATION
Surname __________________________________________ Name _____________________________________
District _____________________________________________Hospital/Clinic _______________________________
Hospital/Clinic tel ___________________________________ Hospital/Clinic fax ___________________________
Town/village residing for the past six months __________________________________________________________
Has this person worked as a miner? y y y y
TREATMENT HISTORY FROM EXISTING MEDICAL RECORDS (Check through all available documents to determine whether the TB suspect had been treated/registered before)
If yes, what was the outcome of the last course of treatment?
TREATMENT HISTORY GIVEN BY THE TB SUSPECT (Ask the following questions to the TB suspect) GO TO SECTION C1 GO TO SECTION C2 How long have you been sick? Have you had the same symptoms in the past? Have you had other symptoms of lung disease in the past? Have you had chest x-rays in the past? Have you had sputum tests in the past? Have you taken medication for more than one month in the past? “ Yes Have you ever received injections for more than one month? Where were you treated? Hospital Workplace When were you treated? How long was the treatment? <1 month 1-2 months 3-4 months 4-6 months How many courses of treatment did you receive?
Should this suspect be found to have TB, what treatment regimen will you use?
“ Regimen I (new cases)“ Regimen II (retreatment cases)
Name of doctor/nurse ________________________________ Signature ___________________________________________
COLLECT THE SPUTUM SPECIMEN BEFORE ANY TB TREATMENT IS GIVEN PLEASE ENSURE THAT THE COMPLETED FORM ACCOMPANIES THE SPUTUM SPECIMEN TO THE LABORATORY - THANK YOU - Tuberculosis Research Lead Programme Operational and Policy Research
Private Bag X385, Pretoria 0001, South Africa
The
1 Soutpansberg Road, Arcadia, Pretoria, South Africa
Tel +27 (0)12 339-8550 • Fax +27 (0)12 325-5970
Medical
Director: Dr Karin Weyer (karin.weyer@mrc.ac.za)
Research
Laboratory enquiries: Jeannette Brand • Tel +27(0)12 339 8565
Council
NATIONAL SURVEY OF TUBERCULOSIS DRUG RESISTANCE
KWAZULU NATAL PRELIMINARY LABORATORY REPORT REFERRAL DISTRICT RECEIVED PROCESSED SPECIMEN TYPE SPUTUM ASSESMENT MICROSCOPY RESULT CULTURE RESULT FOLLOW-UP REPORT
Susceptibility and identification test results to follow
Tuberculosis Research Lead Programme Operational and Policy Research
Private Bag X385, Pretoria 0001, South Africa
The
1 Soutpansberg Road, Arcadia, Pretoria, South Africa
Tel +27 (0)12 339-8550 • Fax +27 (0)12 325-5970
Medical
Director: Dr Karin Weyer (karin.weyer@mrc.ac.za)
Research Council KWAZULU NATAL FINAL LABORATORY REPORT REFERRAL DISTRICT RECEIVED PROCESSED SPECIMEN TYPE SPUTUM ASSESMENT MICROSCOPY RESULT CULTURE RESULT DIFFERENTIAL TEST RESULTS Biological Biochemical IDENTIFICATION DRUG SUSCEPTIBILITY TEST RESULTS Annexure 3 NATIONAL SURVEY OF TUBERCULOSIS DRUG RESISTANCE IN KWAZULU-NATAL SELECTED TREATMENT UNITS PER DISTRICT Patients District Facility Required Actual
Prescription List for Final Expense Application For use with Final Expense applications on Insureds ages 45 and up 1. This list is not all inclusive and is intended as a guide only. All cases subject to review. 2. This list only identifies some uses for the medications. There may be other uses that could positively or negatively impact the final classification of the case being reviewed. We onl
KEEP OUT OF REACH OF CHILDREN READ SAFETY DIRECTIONS BEFORE OPENING OR USING Conquest SquareDown 360 ACTIVE CONSTITUENT: 360g/L GLYPHOSATE PRESENT AS THE ISOPROPYLAMINE SALT Conquest SquareDown 360 Herbicide is a water soluble herbicide for non-selective control of many annual, perennial and aquatic weeds in the situations stated in the directions for use table
Tuberculosis Research Lead Programme 
Tuberculosis Research Lead Programme