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NTP Laboratory Request Form 2

The NTP Laboratory Request Form is designed for health workers to request laboratory tests for tuberculosis patients, capturing essential patient information and test details. It includes sections for the patient's history, disease classification, reason for examination, specimen type, and requested tests. The form also outlines the responsibilities of the specimen collector and the medical technologist, ensuring proper documentation and follow-up of results.

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Aubrey Gandionco
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120 views1 page

NTP Laboratory Request Form 2

The NTP Laboratory Request Form is designed for health workers to request laboratory tests for tuberculosis patients, capturing essential patient information and test details. It includes sections for the patient's history, disease classification, reason for examination, specimen type, and requested tests. The form also outlines the responsibilities of the specimen collector and the medical technologist, ensuring proper documentation and follow-up of results.

Uploaded by

Aubrey Gandionco
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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NTP Laboratory Request Form

To be filled out by Health Worker


Name of Collection Unit: ____________________________________ Date of Request: _______________________
Name of Requesting Physician: __________________________________________
Name of Patient: _____________________________________________________ Age: _____ Sex: ______
Address (in Full):__________________________________ Telephone/Cellphone Number: ____________________
History of Treatment: New Retreatment: Relapse PTOU

Transfer –In TALF Others


Treatment after Failure

Disease Classifiaction: Pulmonary Extra-pulmonary, site: __________________

Reason for Examination: Diagnosis Follow-up, TB Case No. __________________

State if Repeat collection and reasons: ________________________________________________________

Type of Specimen: Sputum Others (Specify ____________________________)

Test Requested: DSSM Culture LPA

XpertMTB/RIF DST

Specimen Date of Collection

Name of Specimen Collector: _________________________________Designation of Specimen Collector: ________


(Signature over Printed Name)

Portion below to be filled by Medical Technologist or Microscopist)

Laboratory Serial No. ______________________________________ Date: _______________________________

Smear Microscopy
Specimen 1 2* Xpert MTB/RIF

Visual Appearance**
Reading

 Specimen #2 = not applicable if sputum follow-up.

** Muco-Purulent, blood stained, salivary, etc.,

Date of Examination: __________________________ Examined by: MARIA GLENDA B. VILLAGONZALO, R.M.T.

The completed form (with results) should be sent to the treatment unit, for recording.
A separate Result Form for culture, DST and LPA will be issued.

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