KaviKrishna Telemedicine Care

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Tuberculosis Control Program

Tuberculosis Control Program Form

Personal Information

First Name *

Last Name *

Date of Birth*

Gender *

Male

Female

Others

Contact Number *

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Secondary Contact Number

Address

Street *

City/Town *

State *

Pincode *

TB Diagnosis Information

Date of TB Diagnosis *

Type of TB *

Pulmonary TB (lungs)

Extrapulmonary TB (other organs)

Multi-drug Resistant TB (MDR-TB)

Extensively Drug-Resistant TB (XDR-TB)

Latent TB

Current TB Symptoms (Check all that apply)*:

Persistent Cough

Blood in Sputum

Chest Pain

Fever and Chills

Night Sweats

Weight Loss

Loss of Appetite

Fatigue

Other

Have you received any previous treatment for this condition? *

Yes

If yes, please specify *

Medical and Family History

Do you have any pre-existing conditions? *

Yes

If yes, please specify *

Are you currently taking other medications? *

Yes

If yes, please specify *

Do you have a family history of TB? *

Yes

If yes, please specify *

Have you been tested for HIV? *

Yes

If yes, please specify *

Lifestyle Information

Smoking History

Currently smoking

Former smoker

Never smoked

Alcohol Consumption

Regular

Occasionally

None

TB Treatment Information

Current Treatment Start Date *

Medication(s) Prescribed (if known)

Have you experienced any side effects from TB medications? *

Yes

If yes, please specify *

Do you have transportation/access to visit a health center regularly? *

Yes

Nutrition and financial Information

Do you require nutritional support during treatment? *

Yes

Do you require financial support or assistance with treatment costs? *

Yes

Emergency Information

Emergency Name *

Emergency Relationship *

Emergency Phone Number *

Digital Signature

Full Legal Name *

Signature *

Date of Signature *

Additional Comments or Special Requests

I, the undersigned, confirm that the information provided is accurate to the best of my knowledge. I consent to receive TB treatment and understand that my information will be kept confidential

* required

0361-283 0009

[email protected]

KaviKrishna Telemedicine Care, College road, Kanchan Nagar Rd, Kanchan Nagar, Sualkuchi, Assam 781103, India

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