Saathi Web Application
Home
(current)
Link
Dropdown
Action
Another action
Something else here
Disabled
Search
TB Treatment Form
Name of the State
Name of the District
Name of the Town
Name of the TB UNIT
Name of the PHI where treatment started
Case Identified Place
Public Sector
Private Sector
Name of the facility where identified
Name of the Child
Sex of the Child
Male
Female
Age of the Child
NIKSHAY ID
Height of the Child
Weight of the Child
Name of the Parent/Gaurdian
Contact Number of the Parent/Gaurdian
Address of the child
Contact Number of the Parent/Gaurdian
Name of the District of the child
Aadhar Number of the child / Parent
Area of Living
Slum
Tribal
Migrant
Refugee
Occupation of the Parent
Socio Economic Status
APL
BPL
Name of Treatment Supporter
Designation
MobiLe Number
Initial Home Visit By
Date of Home Visit
Type of Treatment
DOT
Family DOT
ICT Supported
Date of Onset of First Symptom
HCP visited before diagnosis
Disease Classification
Pulmonary
Extra Pulmonary
Type of Patient
None Selected
New
Recurrent
Transfer in
Rx Failure
RX
Others
Previously treated after LFU
Basis Of Diagnosis
None Selected
Microbiologically Confirmed
Clinical TB
Diagnosis Done facility type
Public
Private
H/O of previous ATT
YES
NO
No of months of Treatment
No of months since last episode
Source of Treatment
Public
Private
Treatment Regimen
HIV Related Info
HIV Status
Unknowm
Reactive
NR
Date of Testing
PID Number
CPT initiation Date
Initiated on ART
YES
NO
Date of ART initiation
ART Number
Diabetes Related Info
Diabetes Status
Unknowm
Diabetic
Non Diabetic
RBS
FBS
Initiated on ADT
YES
NO
Date Of Initiation
ADT Number
Other co-morbidity details
TB Treatment
DS-TB
DR-TB
Not initiated
Treatment Facility Type
Public
Private
TB Initiation Date
Date of Initiation of IP Phase
Status of TB Treatment
None Selected
Initiated on 1st Line treatment in same health facility
Initiated on 2nd Line treatment in same health facility
Initiated treatment outside health facility / Outside RNTCP
Dosage Frequency
None Selected
Daily
Intermittent
Drug Formulations
None Selected
FDC
Combipack
Loose Drugs
Type of Regimen
Drug Package
None Selected
PWB
Strips
Weight Band
None Selected
4-7 kgs
8-11 kgs
12-15 kgs
16-24 kgs
24-29 kgs
Follow-up
Pre Treatment
Date of Specimen Collected
CBNAAT test done by facility name
Smear Result
None Selected
Detected
Not Detected
NA
DST Result
End of IP - Date
Date of Specimen Collected
CBNAAT test done by facility name
Smear Result
None Selected
Detected
Not Detected
NA
DST Result
End of Treatment - date
Date of Specimen Collected
CBNAAT test done by facility name
Smear Result
None Selected
Detected
Not Detected
NA
DST Result
Treatment Outcome
Date of Treatment Outcome
Outcome of Treatment
None Selected
Cured
Treatment Completed
Died
Failure
LFU
NE or TE
Post Treatment follow-up
At 6 Months
Follow up Date
Symptoms
C
F
H
W
N
O
NS
CXR
None Selected
Normal
Abnormal Consistent With TB
Smear
None Selected
Detected
Not Detected
Culture
At 12 Months
Follow up Date
Symptoms
C
F
H
W
N
O
NS
CXR
None Selected
Normal
Abnormal Consistent With TB
Smear
None Selected
Detected
Not Detected
Culture
At 18 Months
Follow up Date
Symptoms
C
F
H
W
N
O
NS
CXR
None Selected
Normal
Abnormal Consistent With TB
Smear
None Selected
Detected
Not Detected
Culture
At 24 Months
Follow up Date
Symptoms
C
F
H
W
N
O
NS
CXR
None Selected
Normal
Abnormal Consistent With TB
Smear
None Selected
Detected
Not Detected
Culture
DBT Status-Nutritional Support
Not Selected
Received
Not Received
Not Applied
In Case of Change in Address
Current State
Current District
Current TBU name
Current PHI name
Submit