Patient admission

ETODA Form - Household group admission

Requester details

Admission request date*: Contact phone number of the person requesting admission*:

Person requesting admission*: Email address of the person requesting admission*:

Referring hospital or center*:

Group information

Address of the place of cohabitation*:

Municipality*:

Province*:

Add additional information.

Requester details Other relevant phone numbers (Specialists): Group information Language barrier:

TB patient details Are there TB cases? [Yes/No]

TB patient

Full name*: Address at the time of admission*:

Sex*: Country of birth*:

Age*:

Medical details

Form of TB*: Initial sputum smear microscopy*

Treatment start date*: Requires isolation*

Recommended regimen*: Resistances*:

Recommended days of isolation:

Which resistance:

Nursing details

Food allergy or intolerance*:

Oxygen therapy*

Comments Additional information. TB patient

Phone number: Date of arrival to live in Spain:

CIP: Country of origin (Country the patient has recently come from):

Other phone numbers:

Medical details

Symptom onset date:

Allergy and/or intolerance to any medication

Risk factors HIVDiabetesAlcoholismDrug abuseSmokingImmunosuppressive treatmentOthers

Specify others:

Nursing details Barthel Social details

Language barrier Housing:

Family situation:

Employment situation:

Documentation Medical report* National ID (DNI) CIP Social report Nursing report

Are there ITL cases? [Yes/No]

ITL patient details

Full name*: Phone number*:

Sex*: CIP:

Age*: Country of birth*:

Medical details

Index case (Name)*: PPD* (choose one) Recommended regimen*

Relationship to index case*: Induration diameter (mm)*: Treatment start date (started or recommended)*:

Type of contact (choose one)*: IGRA* Recommended treatment duration*

Comments Additional information ITL patient details Other phone numbers: Date of arrival to live in Spain: Country of origin (Country the patient has recently come from): Social details

Language barrier Housing:

Family situation:

Employment situation:

Documentation Medical report National ID (DNI) CIP Social report Nursing report