Person admission

ETODA Form - TB infection (TBI) 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*:

Patient details

Full name*: Phone number*: Province*:

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

Age*: Municipality*:

Is the index case known?*

Index case

Index case (Name and relationship) PPD (choose one) Recommended regimen

Type of contact (choose one): Induration diameter (mm): Treatment start date (started or recommended):

Cohabitant: IGRA Recommended treatment duration

Comments Add additional information.

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

CIP: Date of arrival to live in Spain:

Other phone numbers:

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

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