Culture & Sensitivity History Form

Patient Name:______________________________ PIN # _____________________________________________

Date of Sampling:___________________________ Sample Source (Type):________________________________
1. Purpose of C/S prescribed:_________________________________________________________
2. Is the patient is taking Antibiotic Therapy?____________________________________________
Last Dose taken time:_____________________________________________________________
Antibiotics Names:_______________________________________________________________
(At least 2 – 3 days gap is recommended from antibiotics But For critical patients sample can be taken just before the
next antibiotic dose time)
3. Presence Inflammation/Redness at the site of wound/skin:____________________________________
4. Presence of Fever/Temperature:_________________________________________________________
5. Presence of Cough:___________________________________________________________________
6. Pain in Urination:____________________________________________________________________
7. Any other Sign & Symptoms:__________________________________________________________
Advised By:__________________________________History Taken By:_________________________________

Culture & Sensitivity History Form

Patient Name:______________________________ PIN # _____________________________________________

Date of Sampling:___________________________ Sample Source (Type):________________________________
8. Purpose of C/S prescribed:_________________________________________________________
9. Is the patient is taking Antibiotic Therapy?____________________________________________
Last Dose taken time:_____________________________________________________________
Antibiotics Names:_______________________________________________________________
(At least 2 – 3 days gap is recommended from antibiotics But For critical patients sample can be taken just before the
next antibiotic dose time)
10. Presence Inflammation/Redness at the site of wound/skin:____________________________________
11. Presence of Fever/Temperature:_________________________________________________________
12. Presence of Cough:___________________________________________________________________
13. Pain in Urination:____________________________________________________________________
14. Any other Sign & Symptoms:__________________________________________________________

Advised By:__________________________________History Taken By:_____________________________________