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FORM 1

PREVENTION AND CONTROL OF DISEASE ORDINANCE
(Cap. 599)

TUBERCULOSIS NOTIFICATION

Particulars of Infected Person

 

Name in English:

 

Name in Chinese:

Age / Sex:

I.D. Card / Passport No.:

Residential Address: 

 

Telephone No.:
 (Home) :

 (Mobile) :
Patient :
Family member :

 (Office / school / others):

 

Name and address of workplace / school / other institution:

Job title / Class attended :

Hospital / Clinic sent to (if any):

Hospital No.:

Site of TB (please ü all applicable)

Sputum
(please
ü and attach laboratory report if available)

Other specimens
(specify and
ü below):

Lung

Meninges

Pleura

Bone & Joint

Lymph node

Urinary system

 

Smear

Culture

PCR test

Smear

Culture

Miliary

Genital system

Positive

 

 

 

 

 

Other(s) (please specify):

Negative

 

 

 

 

 

Unknown

 

 

 

 

 

Not done

 

 

 

 

 

Duration of stay in Hong Kong: ___________ Years

History of past treatment for TB
(delete whichever not applicable): Yes / No

If yes, YEAR first receiving treatment: ___________

Disposal (please ü in front boxes and specify):

Treatment started on: _____________ (Date: dd/mm/yyyy)

On observation

Referred to _____________ Hospital / Clinic / Private Practitioner

Died on: _________________ (Date: dd/mm/yyyy)

 

(Please DELETE whichever is not applicable)

I will arrange for examination of contacts myself.  /  Please arrange for examination of contacts.

Further Remarks:

 

Notified under the Prevention and Control of Disease Regulation by

 

Dr. __________________________________  of _______________________________Hospital / Clinic / Private Practice
           (Full Name in BLOCK Letters)

_______________________________ Ward / Unit / Specialty on ________ / ________ / __________ (Date: dd/mm/yyyy)

Telephone No.: ______________________

Fax No.: ______________________

_______________________________
(Signature)

 

 

 

 

 

 

 

DH 1A(s)(Rev. Jul 2008)

  Last Revision Date : 14 Jul 2008