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
Name of the facility where identified
Name of the Child
Sex of the Child
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
Occupation of the Parent
Socio Economic Status
Name of Treatment Supporter
Designation
MobiLe Number
Initial Home Visit By
Date of Home Visit
Type of Treatment
Date of Onset of First Symptom
HCP visited before diagnosis
Disease Classification
Type of Patient
Basis Of Diagnosis
Diagnosis Done facility type
H/O of previous ATT
No of months of Treatment
No of months since last episode
Source of Treatment
Treatment Regimen
HIV Related Info
HIV Status
Date of Testing
PID Number
CPT initiation Date
Initiated on ART
Date of ART initiation
ART Number

Diabetes Related Info
Diabetes Status
RBS
FBS
Initiated on ADT
Date Of Initiation
ADT Number
Other co-morbidity details
TB Treatment
Treatment Facility Type
TB Initiation Date
Date of Initiation of IP Phase
Status of TB Treatment
Dosage Frequency
Drug Formulations
Type of Regimen
Drug Package
Weight Band
Follow-up
Pre Treatment
Date of Specimen Collected
CBNAAT test done by facility name
Smear Result
DST Result
End of IP - Date
Date of Specimen Collected
CBNAAT test done by facility name
Smear Result
DST Result
End of Treatment - date
Date of Specimen Collected
CBNAAT test done by facility name
Smear Result
DST Result
Treatment Outcome
Date of Treatment Outcome
Outcome of Treatment
Post Treatment follow-up
At 6 Months
Follow up Date
Symptoms
CXR
Smear
Culture
At 12 Months
Follow up Date
Symptoms
CXR
Smear
Culture
At 18 Months
Follow up Date
Symptoms
CXR
Smear
Culture
At 24 Months
Follow up Date
Symptoms
CXR
Smear
Culture
DBT Status-Nutritional Support
In Case of Change in Address
Current State
Current District
Current TBU name
Current PHI name