STOCK CARD
Item: INTENSIVE (Rifampicin 150mg, Isoniazid 75mg, Pyrazinamide Dosage/Form: 900mg per tab
400mg, & Ethambutol Hydrochloride 275mg tablets)
CODE: Packaging unit:
Remarks:
DATE ORIGIN IN OUT STOCK REMARKS/ SIGNATURE
STOCK CARD
Item: MAINTENANCE (Rifampicin 150mg, Isoniazid 75mg tablets) Dosage/Form: 225mg per tab
CODE: Packaging unit:
Remarks:
DATE ORIGIN IN OUT STOCK REMARKS/ SIGNATURE
PATIENT STOCK CARD
Patient Name: Date Started:
Address: Birthday & Age: Sex & Status: Weight & Height:
Treatment Partner: Tablets per day:
Generic Name: Rifampicin 150mg, Isoniazid 75mg, Phase: INTENSIVE
Pyrazinamide 400mg, & Ethambutol Hydrochloride 275mg
tablets
Registration group: ( ) NEW ( ) Relapse ( ) Restarter/ Failure
1st follow-up date(56 days/2months): DSSM Result:
DATE TOTAL GIVEN BALANCE REMARKS/ SIGNATURE
PATIENT STOCK CARD
Patient Name: Date Started:
Address: Birthday & Age: Sex & Status: Weight & Height:
Treatment Partner: Tablets per day:
Generic Name: Rifampicin 150mg, Isoniazid 75mg tablets Phase: MAINTENANCE
Registration group: ( ) NEW ( ) Relapse ( ) Restarter/ Failure
2nd follow-up (140 days/5th month): DSSM Result:
3rd follow-up (168 days/ 6th month): DSSM Result:
DATE TOTAL GIVEN BALANCE REMARKS/ SIGNATURE
PATIENT STOCK CARD
Patient Name: Date Started:
Address: Birthday & Age: Sex & Status: Weight & Height:
Treatment Partner: Tablets per day:
Generic Name: Rifampicin 150mg, Isoniazid 75mg tablets Phase: MAINTENANCE
Registration group: ( ) NEW ( ) Relapse ( ) Restarter/ Failure
DATE TOTAL GIVEN BALANCE REMARKS/ SIGNATURE
