Laboratory Request Form For Tb Smear Microscopy And Xpert Mtb/rif

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Laboratory Request Form for TB Smear Microscopy and Xpert MTB/RIF
Date of Request ______________________________
Patient Information
Name _________________________________________________________________________
Age____________________
DOB _____________
Sex M □ F □
Complete address ________________________________________________________________
_______________________________________________________________________________
Contact Person
Name _________________________________________________________________________
Complete address ________________________________________________________________
_______________________________________________________________________________
Phone ___________________________________Phone 2_______________________________
General Treatment Information
Health Unit_______________________________ Patients TB No_________________________
Reason for examination
Diagnosis□
Follow-up □
Month of Follow-up _____________
Doctor__________________________________
Specimen Collection Details
Date of Collection ________________________
Time of Collection____________________
Number in series (circle the number) Specimen
[1]
[2]
[3]
No. sputum samples sent with this form ______________________________
Collected by __________________________________________________________
RESULTS (to be completed by laboratory)
Lab Serial No
Sputum ID No
Date Received
Spec
Date of
Date of
Visual
AFB
Xpert MTB/RIF Result
Type
1
Collection
Exam
Appearance
2
Smear
Result
3
1
2
3
1
S=Sputum
O=Other
2
M=Mucoid
B=Blood-stained
S=Salivary
P=Purulent
MP=Mucopurulent
3
Grading system for AFB smear result
Neg
No AFB seen in at least 100 fields
Actual AFB #
1—9 AFB per 100 fields
1+
10—99 AFB per 100 fields
2+
1—10 AFB per field in at least 50 fields
3+
>10 AFB per field in at least 20 fields
Date________________________
Examined by (Signature)________________________________

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