Useful Information

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:

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

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

Telephone No.: ______________________

Fax No.: ______________________

_______________________________
(Signature)