RHU/IC: ______________________________ BARANGAY: _________________________ DATE: ___________________

Name of Patient: __________________________________ Sex: ____ Age: ______ Contact Number: ___________________

SCREENING FORM

1. Do you experience any of the following?

Cough of 2 weeks duration

Unexplained fever of 2 weeks duration
Night sweats of 2 weeks duration
Unintentional and unexplained weight loss
If YES to at least 1, identify as presumptive TB. Request for bacteriologic test.
If NO to all, proceed to question #2.
2. Have you had a chest X-ray done in the past year?
YES
NO
If YES, inquire about the result and determine of bacteriologic testing needed.
If NO, offer Chest X-ray screening.

If resources are limited, you have the option t prioritize those with TB risk factors as primary clients for chest X-ray screening.

Risk factors include:

a. Contacts of TB patients
b. Those ever treated for TB (i.e. with history of previous TB treatment)
c. People living with HIV (PLHIV)
d. Elderly (<60 years old)
e. Diabetics
f. Smokers
g. Health-care workers
h. Urban amd rural poor (indigents)
i. Those with other immune-suppresssive medical conditions (silicosis, solid organ transplant, connective tissue or
autoimmune disorder, end-stage renal disease, on long corticostreoid course, alcoholics or substance abuse, receipt of
chemotherapy or other forms of medical treatment for cancer)

RHU/IC: ______________________________ BARANGAY: _________________________ DATE: ___________________

Name of Patient: __________________________________ Sex: ____ Age: ______ Contact Number: ___________________

SCREENING FORM

1. Do you experience any of the following?

Cough of 2 weeks duration

Unexplained fever of 2 weeks duration
Night sweats of 2 weeks duration
Unintentional and unexplained weight loss
If YES to at least 1, identify as presumptive TB. Request for bacteriologic test.
If NO to all, proceed to question #2.
2. Have you had a chest X-ray done in the past year?
YES
NO
If YES, inquire about the result and determine of bacteriologic testing needed.
If NO, offer Chest X-ray screening.

If resources are limited, you have the option t prioritize those with TB risk factors as primary clients for chest X-ray screening.

Risk factors include:

a. Contacts of TB patients
b. Those ever treated for TB (i.e. with history of previous TB treatment)
c. People living with HIV (PLHIV)
d. Elderly (<60 years old)
e. Diabetics
f. Smokers
g. Health-care workers
h. Urban amd rural poor (indigents)
i. Those with other immune-suppresssive medical conditions (silicosis, solid organ transplant, connective tissue or
autoimmune disorder, end-stage renal disease, on long corticostreoid course, alcoholics or substance abuse, receipt of
chemotherapy or other forms of medical treatment for cancer)
RHU/IC: ______________________________ BARANGAY: _________________________ DATE: ___________________

Name of Patient: __________________________________ Sex: ____ Age: ______ Contact Number: ___________________

SCREENING FORM

1. Do you experience any of the following?

Cough of 2 weeks duration

Unexplained fever of 2 weeks duration
Night sweats of 2 weeks duration
Unintentional and unexplained weight loss
If YES to at least 1, identify as presumptive TB. Request for bacteriologic test.
If NO to all, proceed to question #2.
2. Have you had a chest X-ray done in the past year?
YES
NO
If YES, inquire about the result and determine of bacteriologic testing needed.
If NO, offer Chest X-ray screening.

RHU/IC: ______________________________ BARANGAY: _________________________ DATE: ___________________

Name of Patient: __________________________________ Sex: ____ Age: ______ Contact Number: ___________________

SCREENING FORM

1. Do you experience any of the following?

Cough of 2 weeks duration

Unexplained fever of 2 weeks duration
Night sweats of 2 weeks duration
Unintentional and unexplained weight loss
If YES to at least 1, identify as presumptive TB. Request for bacteriologic test.
If NO to all, proceed to question #2.
2. Have you had a chest X-ray done in the past year?
YES
NO
If YES, inquire about the result and determine of bacteriologic testing needed.
If NO, offer Chest X-ray screening.