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Form 3 Treatment Registry

The document is a Treatment Register Form for leprosy cases, detailing patient information, treatment outcomes, and reactions during treatment. It includes sections for recording the date of supervised doses, episodes, and remarks regarding the patient's status. The form categorizes cases as new, relapse, or transferred in, and tracks treatment progress and outcomes.

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Josanne Wadwadan De Castro
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172 views3 pages

Form 3 Treatment Registry

The document is a Treatment Register Form for leprosy cases, detailing patient information, treatment outcomes, and reactions during treatment. It includes sections for recording the date of supervised doses, episodes, and remarks regarding the patient's status. The form categorizes cases as new, relapse, or transferred in, and tracks treatment progress and outcomes.

Uploaded by

Josanne Wadwadan De Castro
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLS, PDF, TXT or read online on Scribd
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NLCP Form 3

TREATMENT REGISTER FORM

REACTION
EHF TREATMENT OUTCOME
DATE FOR THE SUPERVISED DOSE NO. OF
SCORE EPISODES (date of last dose)

REMARKS

During Tx

DEFAULTED
Post Tx

TRANS-OUT

Reclassified
TxC/Cured
Upon TxC
Upon Dx

DIED
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Leprosy Case No.
NAME Classification Type of Case
Age Sex
Date of
Registration( Address
mm-dd-yy)
PB MB New Relapse RAD Trans-in
(Family name, First Name,M.I.)
(in years) (M/F)
LEPROSY

Case

Date Started Tx
Re-classified

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