Certification of Treatment Completion FORM 5.

TB AND TPT PATIENT

BOOKLET
This is to certify that Mr./Ms.
, bearer of this NTP Patient
Booklet, has complied with the required treatment for
[  ] DS-TB Treatment TB/ TPT Case No.:
[  ] DR-TB Treatment
[  ] TB Preventive Treatment
at DOTS Facility.
S/he is no longer infectious. Treatment Facility:

Issued this th day of , 20 .

Physician Facility Address:
(Signature over Printed Name)

Schedule of Follow-up Remarks GX/ TBC

PT 6
Facility Contact No.:
PT 12
PT __
PT __

12 1
Patient Name:
PhilHealth No.:
Diagnosis: [  ] TB Disease  [  ] TB Infection
Date of Diagnosis:
TB Disease Classification: [  ] Pulmonary
[  ] Extra-pulmonary:

[  ] Bacteriologically-confirmed
[  ] Clinically-diagnosed
 b. For DS- and DR-TB, my sputum shall be examined on a prescribed schedule;
[  ] New
[  ] Retreatment

[  ] Drug-susceptible
[  ] Drug-resistant
Location of Treatment: [  ] Facility-based
[  ] Community-based
[  ] Home-based
Name of Treatment Supporter:
Contact Information of Treatment Supporter:
Schedule of Treatment:
DAT-Support:
2 11
I understand and agree to the following:
1. I shall answer honestly all questions given to me by the health worker and
I shall provide data and records relevant to the queries. I understand that
collection of my information is necessary and important for my diagnosis,
treatment, and care and that I can exercise my rights regarding data collected
from me.
2. I shall adhere and complete the prescribed number months of treatment (from
4 to 24 months, depending on the laboratory results and physician assessment)
with anti-TB medicines under direct supervision. Treatment interruption
will lead to worsening of my condition and development of (further) drug-
resistance, making my disease more difficult to treat.
3. To monitor my treatment progress,
a. A doctor shall conduct monthly medical check-up;
c. For DR-TB, additional blood and laboratory tests such as but not limited to
ECG, hearing test, and eye test shall be done as well to monitor effect of
drugs to my body.
4. To ensure successful treatment, I shall:
a. Take the medications daily, at the right time, with the right dose under the
supervision of a treatment partner;
b. Not stop taking the drugs unless there is an advice from the TB physician;
c. Stop or avoid smoking, drinking alcohol, and use of prohibited drugs while on
treatment.
5. Possible side effects of anti-TB drugs have been explained to me and I shall
follow advise by health worker on how these can be managed when experienced.
6. To prevent the spread of my disease, I shall:
a. Cover my mouth and nose with handkerchief while coughing and sneezing;
b. Dispose my sputum properly based on the instruction provided by the health
care provider (e.g., spitting on a tissue paper and disposing it to a trash bin
disinfected with Sodium hypochlorite, e.g. Chlorox, or spitting directly to the
toilet bowl);
c. Keep my room well-ventilated by opening windows and letting the sunrays
in.
7. All the tests for diagnosis and medications for the whole duration of treatment
of TB patients shall be provided by the National TB Control Program free of
charge.
 ANO ANG DATA PRIVACY ACT? Treatment Start Date:
Ito ang polisiya ng Estado upang protektahan ang karapatang pangtao Regimen Type and Regimen:
sa “privacy” at sa komunikasyon habang sinisigurado ang libreng daloy ng
impormasyon upang isulong ang pagbabago at pagunlad.
GAANO KAIMPORTANTE ANG IYONG DATOS?
Sa tamang pag-gamit ng iyong datos, ikaw ay nakakagamit ng mga serbisyo ng No. to be Taken (Date on Top)
gobyerno. Ngunit, kung ito’y pababayaan, hatid nito ay perwisyo sa iyong buhay. Kaya Drug Strength Unit
naman nakabubuting alamin ang “Data Privacy Act” at ang mga karapatang nakukuha
mo dito bilang indibidual.

ANO ANG IYONG DATA PRIVACY RIGHTS?

Bago ang pagsusuri at
gamutan, siguraduhin
na ang manggagawang
pangkalusugan ay
ipinaalam sa iyo na ang
iyong personal na datos
ay kokolektahin mula sa
pagsusuri hanggang sa >
Maaari mong makita Ipaalam sa iyong Ipaalam sa iyong
ang iyong sariling mga manggagawang manggagawang
rekord sa tulong ng pangkalusugan kung HINDI pangkalusugan kung nais
isang manggagawang mo nais maproseso ang mong ipatanggal ang
pangkalusugan. iyong mga datos. iyong datos sa ‘database’/
talaan/rekord.
‘post-treatment follow-up’. sa iyo kung paano at saan
Tiyaking ipinaalam nila > gagamitin ang iyong datos.

Kung sa iyong palagay
ay nilabag ang iyong
karapatan sa ‘data
privacy’, ipagbigay alam sa
pamunuan ng pasilidad sa
pamamagitan ng pormal
na liham at magpadala ng
kopya sa ntp.mne@doh.
gov.ph.
REFERENCE:
Know Your Rights. (2018 September 25). Retrieved from https://www.privacy.gov.ph/know-your-rights
Ipagbigay-alam sa
iyong manggagawang
pangkalusugan kung
sa iyong palagay ay
hindi tama ang datos na
mayroon sila at nais mong
iwasto ito.
Ang kopya ng iyong mga
resulta sa laboratoryo o
diagnostic examinations ay
maaring makuha sa tulong
ng iyong manggagawang
pangkalusugan. Maari ka
ring humingi ng medical
certificate o abstract, kung
kinakailangan.
Number of Contacts:
Contact Tracing Schedule:
Iulat ang anumang
paglabag sa iyong mga
karapatan patungkol sa
‘data privacy’ sa pinuno
ng pasilidad sa loob Date of Outcome:
ng 24 oras pagkatapos
itong matuklasan sa
pamamagitan ng pormal na
Outcome:
liham. Magdala ng kopya
ng ulat sa NTP Mangament [  ] Cured [  ] Failed [  ] Died
Office sa pamamagitan ng
sulatroniko sa ntp.mne@ [  ] Completed [  ] Lost to Follow-up [  ] Not Evaluated
doh.gov.ph.

10 3
 Date Collected Smear Mx/ TB LAMP GX/TBC TB Patient’s Rights
Right to life Every person is entitled to life-saving health care and to the highest
Right to health attainable standard of physical and mental health.
S1 GX: Every person is treated NOT as a problem, but as a human being in
Right to dignity health care.
S2 GX: Right to freedom
(against cruelty)
Every person has the right to be free from torture, degrading treatment
or punishment.
Every person is equal before the law and entitled without discrimination
B Right to equality to equal protection of the law.
No person shall be deprived of their liberty except on grounds
Right to liberty and established by law. People deprived of liberty must be treated with
1 security humanity and respect for their inherent dignity.
Every person has the right to choose their own residence and movement
Right to move
2 according to the established laws.
Right to privacy and Every person has the right NOT to be subjected to interference of their
family privacy.
3 Right to confidentiality Every person has the right to confidentiality of their information or data.
Right to information Every person has the right to seek, receive and impart information.
4 Right to informed Every person has the right to informed consent.
consent
5 Right to education
Every person has the right to education without discrimination. Children
must be accommodated even if they are still receiving treatment with
measures to continue education.
6 No person shall be held in slavery or be subjected to forced or
Right to work compulsory labor. Every person has the right to choose work and be
protected while employed.
7 Right to adequate food Every person has the right to be free from hunger and malnutrition.
Right to housing Every person has the right to adequate and appropriate housing.
8 Right to water and Every person has the right to access safe drinking water, and sanitation
sanitation services.
9 Every person has the right to social security and social insurance.
Right to social security People who acquire infections as a result of their employment have the
right to compensation for medical and other costs associated with the
10 disease.
Every person has the right to freedom of expression through any
Right to expression medium without interference from authorities.
11 Every person has the right to freedom of peaceful assembly and
Right to assembly association.
12 Right to participation Every person has the right to take part in public affairs through their
organizations and freely chosen representatives.
Every person charged with a criminal offence has the right to a fair and
PT 6 Right to due process public hearing without delay by a competent tribunal established by law.
Every person has the right to enjoy the benefits of scientific progress and
Right to science
PT 12 its applications.
Source: Declaration of the Rights of People Affected by Tuberculosis www.stoptb.org

4 9
 Date Collected/Done

8
Lab Test
Result

9
8
7
6
5
4
3
2
1
0

12
11
10

PT
PT 

Monthly Doses
Taken

Cum. Doses
Taken

Monthly
Missed Doses
5

% Adher.

Weight (kg)

Height (cm) for

Children

Lab Test Due

Date Test Due

 Month 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

10

11

12

6 7