SYMPTOMS BASED SCREENING TOOL (CHEST INFECTIONS)
1. Any client responding to cough for more than 2 weeks is mandatory for LAB screening irrespective of presence or absence of other symptoms.

2. Any client / patient responding “YES” to cough or contact with a known TB case in addition to one other symptom and signs is ELIGIBLE for LAB TB screening.
Email address *
DATE OF SCREENING: *
MM
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DD
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YYYY
REGION: *
DISTRICT: *
Your answer
HEALTH FACILITY
Your answer
NAME OF NGO
Your answer
NAME OF CLIENT *
Your answer
AGE *
Your answer
GENDER *
CONSULTATION *
SYMPTOMS AND SIGNS *
Required
LAB SCREENING ELIGIBILITY *
INVESTIGATION REQUESTED / ACTION TAKEN *
Required
LAB TEST RESULTS *
TREATMENT INITIATION *
NAME OF TREATMENT VOLUNTEER
Your answer
FUNDING PERIOD AND SOURCE (please specify date started)
MM
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DD
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YYYY
FUNDING PERIOD AND SOURCE (please specify date ending)
MM
/
DD
/
YYYY
FUNDING SOURCE
Your answer
HIV SERVICE TO TB+ PERSON
HIV SERVICES RESULT
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