Patient admission

Clinic Admission Form

Requester details

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

Referring hospital or center*: Email address of the person requesting admission*:

Person requesting admission*:

Doctor details The details are not the same as the requester's.

Full name of the responsible doctor*:

Email address of the responsible doctor*:

Phone number of the responsible doctor*:

Patient details

Full name*: Phone number*: Province*:

Sex*: Address at the time of admission*: Country of birth*:

Age*: Municipality*:

Medical details

Form of TB*: Recommended regimen*:

Initial sputum smear microscopy* Resistances*:

Which resistance:

Treatment start date*: Requires isolation*

Nursing details

Mobility problems*

Food allergy or intolerance*:

Oxygen therapy*

Comments Add additional information.

Requester details Other relevant phone numbers (Specialists): Patient details

Country of origin (Country the patient has recently come from): Date of arrival to live in Spain:

CIP:

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