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LABORATORY INVESTIGATION FORM

Download the Laboratory Investigation Form Here



INFORMATION REQUIRED FOR ALL SPECIMENS SUBMITTED TO CARPHA


Section Essential Information

1. Patient Information

Patient demographics e.g. National Patient ID and/or Laboratory Number, Age, D.O.B., Sex, Address, Occupation (where relevant)

2. Referring Doctor

Name of Referral Doctor/ Hospital with contact information

3. Provisional Diagnosis, Additional Notes

Clinical diagnosis:

Provide any past clinical information on patient including past treatment, treatment failure, relapse or non-compliance. Indicate if patient is suspected of pulmonary TB (PTB) or a suspected MDR-TB case.

4.Food/Animal/Environment Sample Details

Specimen type

5. Case

Type of case e.g. Single/Outbreak/Survey

6. Date of Onset of Illness

Date of onset of illness

7. Outcome

Hospitalization status or death

8. Signs and Symptoms

Clinical signs and symptoms:

Please check all symptoms exhibited by patient. Also include HIV status and any treatment information with start date if known.

9. Syndromic Classification

 

10. Immunization History

When applicable - travel history; vaccination history/status

11. Laboratory Use and Physician/EHO Use

LABORATORY INVESTIGATION(S) requested

Date of collection of specimen(s)

Laboratory results of all tests performed in country re that specimen, including date tested

Indicate AFB smear microscopy results if performed on the submitted specimen.

Date specimen referred to CARPHA for testing

Caribbean Public Health Agency © 2014