NMC - FindCase

Case ID:

NMC Diagnosed:

Patient Name:

Patient Surname:

ID/Passport Number:

Notified from:

Notified to:

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Clinical

Lab

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Case type:

Facility details

Facility

District

Facility contact No

File / Folder No

HPRS-PRN

Notification Date

Notifier details

Name

Surname

Contact No

Notifier SANC/HPCSA

Demographics

Title

Firstname

Surname

Identification Type

Date of birth

Age

Sex

Pregnancy status

Contact No

Residential address

Country

Province

City / Town

Suburb

Address

Postal code

Employer / Educational institution details

Employement status

Employer / Institution

Medical condition details

NMC Diagnosed

Contact History

Method of Diagnosis

Symptoms

Treatment description

Symptom onset date

Diagnosis date

Admission status

Ward name

Patient vital status

Death date

Did patient travel outside of usual place of residence?

Clinical details

Asthma

Cancer

Diabetes

COPD

Obesity

Hypertension

Pregnant

HIV

Other factors

On ART?

Virally Suppressed

On TB Treatment

TB Start datet

Medical condition details

NMC Diagnosed

Diagnosis date

Cough present

Cough duration

Vital Status

Date of death

Method of diagnosis

Clinical Symptoms

X-Ray

Urine-LAM

Microbiological

TB Treatment details

Previous TB Treatment

HIV Status

Clinical site

TB Type

Type of treatment

Specified of TB site (if applicable)

Treatment start date

Any household TB contact < 5 years

Any household contact with HIV

Vaccination history

Vaccination status

Last vaccination date

Specimen

Specimen collected

Specimen date

Specimen barcode

Episode No:

Specimen type

Specimen collected date

Specimen registered date

Lab Test Performed

Organism Identified

Final Result

Result value

Authorised date

Testing Lab Details

Pathologist

Lab name

Province

District

Sub-District

Lab Contact No.

Comments

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