MD

DR TB T
TREATMMENT CA
ARD FO
ORM 01
PATIEN
NT INFO
ORMATIO
ON Code
e Regis
stration group
g Se
elect one Class
sification of previo
ous drug use
only
Medical R
Registratio
on Number(MRN): _
_________
________
_ 1 Used second-liine drugs previouslyy?
New
MDR TB registratio
on numberr: ______
_________
____ 2 Yess N
No
Relap
pse
Name: __
________
_________
_____ __
___ 3 If yess, specify_
_________
_________ _____
After Lost to Fo
ollow up
Sex: M F 4 After failure of first
f treatm
ment
Age: ____
________
__
5 After failure of rer treatme
ent
Region: _
_________
________
__ Transsfer in (from anotherr treatme
ent
6
Zone/Woreda/Housse No : __
_________
________
_________
_______ initiatiing site)
Site: Pulmonary E
Extra Pul Otherr (previoussly treatedd with
7 unkno own outco ome statuss)
ulmonary, specify siite:______
If extra pu ________
________
Resistancce type: R
RR/ MDR-T
TB / XDR--TB/ Poly resistant
r TB/HIV
V
Med
dical Dia
agnosis
s other than
t tub
berculos
sis
Initial weight:_____
_____ Height (CM): ________
____ Typee (i.e. diab
betes, hype
ertension, Durattion in HIV Te
esting don
ne Y N Unknown
Date trea
atment sta
arted(DD/M
MM/YY/):_
_____/ ___
__/ ____ cardiiomyopath hy, HIV, op
pportunisttic yeear
infec
ctions….) Date of
o Test __
__/ ___ /__
__ Result:____
Started
d on CPT((DD/MM/Y
YY):____/_
____/____
_
Treatment Sup
pporter
Started
d on ART((DD/MM/Y
YY):____/_
____ /___
__
Name : __
________
________
Unique
e ART No.________
________
____
Full addre
ess :_____
________
_________
________
_________
________
Telephon
ne:______
_________
_________
________
_________
_
Relationsship :_____
________
_________
________
_________
_

Drug-su
usceptib
bility tes
sting (D
DST) res
sults(No
otation m
method fo
or DST: R = Ressistant, S = Suscceptible, I = Inde
etermina
ate)
Diagnnostic
Date* meth
hod S H R E Z Km Am Cm Ofxx Pto Eto PAS Css

Review
w panel meetin
ngs: Date
es and Decision
D ns Con
ntacts Investigation (H
House Hold,
H Clo
ose contact)
Next Na
ame DSST result
Relation MDR TB (No DR/RR//
Date D
Decision date (HH/CC) ning
Screen MDDR/XDR)
(P/N
N)

MDR TB
B Regim
men (date
e treatmen
nt started
d and dossage (mg
g), change of dosa
age, and cessation of drug
gs)
Reason fo
or drug
Date weight Km/Am Cm Lfx M
Mfx Pto
o/ Eto Cs PAS V.B 6 Z cha
ange/discon
ntinuation

Treatm
ment outcome C
Chest x--ray
Lo
ost to follow
w Not
Outcom
me C
Cured C
Completed Died
d Fa
ailed up Evaluatted R
Result

Mark on
ne B
Base line
Date(D/M/Y)
I
Improved
d() No
o change() Dete
eriorated ()
Anti TB
B Drug Ab
bbreviatio
ons
End of Inte
E ensive
Gro
oup I Grroup II G
Group III Group IV
V Group V P
Phase
Isoniazid
d H Amikacin Am
m ofloxacin O
Ofx Proth
hionamide Pto Bedaquiline
B e Bdq
q End of
E
C
Continuatio
on
Rifampiccin R Kanamyycin Km
m Levofloxacin L
Lft Ethio
onamide Eto Linezoid
L Lzd
d

Ethambu
utol E Capreom
mycin Cm
m Moxiflo
oxacin M
Mfx Cyclo
osrine Cs Clofazimine
C e Cfzz
Commentts:
Pyrazina
amide Z Streptom
mycin S Pra aamino Amoxacillin
A Am
mx __________
________________________________
____________________
Saliccyclic acid PAS
High
H dose INH H __________
________________________________
____________________
__________
________________________________
____________________
Thiocacetaz
T zone Th
__________
________________________________
____________________
__________
________________________________
___________________
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