Patient admission

ETODA Form - TB patient

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*:

Medical details

Form of TB*: Recommended regimen*:

Treatment start date*: Resistances*:

Requires isolation*

Recommended days of isolation:

Which resistance:

Risk factors* HIVDiabetesAlcoholismDrug abuseSmokingImmunosuppressive treatmentOthers

Specify others:

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):

Medical details

Symptom onset date:

Allergy and/or intolerance to any medication

Social details

Language barrier Housing:

Family situation:

Employment situation:

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