Extrapulmonary Site 2 :_____________________ Name (surname, first name) Age (in years) Sex F Alternative address Physical Address (in full) M INTERIM TUBERCULOSIS TREATMENT CARD BOTSWANA NATIONAL TUBERCULOSIS PROGRAMME Date RegisteredIN ToOUT RegisteredIN ToOUT Transfer/Moved 1 DCB DCBA DCBA Unit TB No. Pre-treatment history and clinical findings Revised September 2005 (MH 1050) Weight in Kg Month Date 1. Transfer/Moved Transfer In – patient transfers in from facility in another reporting unit Transfer Out- patient who has been transferred to another reporting unit for whom treatment outcome is not known. Moved In- patient who moves in from another facility in the same reporting unit Moved Out- patient who moves out to another facility in the same reporting unit 2. Site of Extrapulmonary Lymph nodes Pleura Meninges Bones/Joints Miliary Other sites 3. Patient Category New: a patient who has never had treatment for TB or who has taken antiTB treatment for less than 1 month. A patient previously treated and cured (3 or more years ago) who is diagnosed with TB again should be registered as a New patient as well. Retreatment Categories - All retreatment cases should undergo sputum culture and sensitivities Failure: a patient who is started on a re-treatment regimen after having failed previous treatment. Default: a patient who returns to treatment, positive bacteriologically, following interruption of treatment for 2 months or more. Relapse: a patient previously treated for TB (3 years or less ago) who has been declared cured or treatment completed, and is diagnosed with bacteriologically positive TB. 4. Sputum Examination for AFB Results P = Positive N = Negative Indicate the grading: +; ++; +++; or scanty 5. HIV Status Test 2 HIV test 2 not needed if patient has previously been diagnosed as HIV positive 6. HIV Status and Interventions Date For HIV tests indicate date when test was done For ART and IPT indicate the date when treatment was started Add referral information in the Remarks field. HIV Status and InterventionsDate 6 (dd/mm/yy) Test 1 Positive Negative Test 2 5 Positive Negative ART Yes No IPT before TB diagnosis Yes No (pretreatment) 0 Result 4 Date of Collection At month Sputum Examination for AFB Other Tests TestDateResult Biopsy PPD Other (Specify) Instructions for recording drug administration: On days of supervised drug administration enter healthcare worker’s initials; On self-supervised days enter (▬); On missed treatment days enter (0) Relapse Default Failure Patient Category 3 Pulmonary Tuberculosis Classification New A Omang/Passport Number (if available) I. INITIAL PHASE Prescribed regimens and dosages EHRZS First Line Dose in G/Mg Which corresponds to No.Tabl./Capsules ReserveDose in G/Mg S= Streptomycin H=Isoniazid R=Rifampicin Z=Pryazinamide E= Ethambutol Pre-treatment weight kg Dosages of Drugs in relation to pre-treatment weight Pretreatment weight (in kg) E mg H mg R mg Z mg over Under Drug Reaction Specify……………………… ………………………………

Month Date No. ScreenedNo. Expected No. Date_________ CHEST X-RAY CULTURE & SENSITIVITY REPORTS DateRemarks (include other treatment, referral, or follow-up information ) DateDrugSensitiveResistant H R Z E S CONTACT SCREENING II. CONTINUATION PHASE Cured Died Treatment Completed Defaulted Treatment Failure Transferred Out TREATMENT OUTCOMES 7 Instructions for recording drug administration: On days of supervised drug administration enter healthcare worker’s initials; On self-supervised days enter (▬); On missed treatment days enter (0) 7. TREATMENT OUTCOMES: Cured : Initially smear-positive patient who is smear-negative in the last month of treatment and on at least one previous occasion Treatment Completed : Patient who has completed treatment but does not meet the criteria to be classified as cure or a failure Treatment Failure: Patient who is sputum smear-positive at 5 months or later during treatment Died : Patient who dies for any reason during treatment Defaulted : Patient whose treatment was interrupted for two consecutive months or more Transferred Out : Patient who has been transferred to another reporting district for whom treatment outcome is not known Prescribed regimens and dosagesHRES First Line Dose in G/Mg Which corresponds to No. Tabl./Capsules Reserve Weight at start of continuation phase kg. Dosages of drugs in relation to weight at time of start continuation phase Weight (in kg)HR mg Over Under Patients under 20 kg receive the lower dosage