Patient admission

ETODA Form - Non-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*:

Add additional information.

Other relevant phone numbers (Specialists):

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

Full name*: Country of birth*: Province*

Phone number*: Sex*: Address*

Age*: Municipality*

Medical details

Form of TB*: Recommended regimen*: Resistances*:

Symptom onset date*: Initial sputum smear microscopy*

Treatment start date*: Requires isolation*

Which resistance:

Recommended days of isolation:

Nursing details

Food allergy or intolerance*:

Oxygen therapy*

Comments Additional information. TB patient details

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

Other phone numbers:

Date of arrival to live in Spain:

Medical details Risk factors HIVDiabetesAlcoholismDrug abuseSmokingImmunosuppressive treatmentOthers Allergy and/or intolerance to any medication

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

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

Full name*: Phone number*: Address*

Sex*: Municipality* Province*

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*

Additional information. ITL patient details