Familiyasi:______________________________ Ismi:_________________________Sharifi _______________________________
Tug`ilgan yili: _____/_____/_________ Bemor vazni : ______ Jinsi: □ Erkak □ Ayol BTSJ chandiq: yo`q □ 1 ta □ 2 ta □
Doimiy yashash manzili:______________________________________________________________________________________
Yaqin qarindoshi yoki bolaning ota-onasi: ________________________________________________________________________
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0 guruhi: tuberkulyoz bilan kasallanish havfi yuqori bo`lgan shaxslar
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□ A guruh
ST+bemorlar bilan muloqotda bo`lgan mantu sinamasining natijasi manfiy kattalar;
Bakteriya ajratishdan qat’iy nazar o`pka tuberkulyozining faol shaklidagi bemorlar bilan muloqotda bo`lgan Mantu sinamasining natijasi manfiy 0-18 yoshdagi bolalar
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□ B guruh
LTI li shaxslar;
TB ni birlamchi infitsirlangan (viraj), Mantu sinamasining natijasi musbat bolalar;
BTSJ vaktsinatsiyasi asoratlangan bolalar
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Tekshiruv natijalari
Mantu sinamasi qo`yilganmi □ xa □yo`q sinama qo`yilgan sana: ____/____/_______seriya raqami _________natijasi____________
Diaskintest sinama qo`yilgan sana: ____/____/_______ seriya raqami_____/_____/_________ natijasi____________
Obzor rentgenografiya, flyuorografiya yoki MSKT □ xa □yo`q sana: ____/____/__________ natijasi____________
_____________________________________________________________________________________________________ ______________________________________________________________________________________________________ ________________________________________________________________________________________________________
Mikroskopiya topshirganmi □ xa □yo`q sana: ____/____/________ natijasi__________ Laborator nomeri ____________
Gene-Xpert topshirganmi □ xa □yo`q sana: ____/____/________ natijasi__________ Laborator nomeri ____________
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Davolash jarayonini kechishi
“D” nazoratga olingan sana ____/____/________“D” nazoratga chiqarilgan sana ______/______/_________ Bemor tartib raqami № _________
Dori qabul qilayotgan joyi : _________________________________________ dorini ichishni boshlagan sana: _______/_______/___________
Dorini nojo`ya ta’siri kuzatildimi □ xa □yo`q ____________________
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