Page 125 - Buku Panduan Perkhidmatan MKAKB

MKAK-BPU-K03

MKAK-BPU-K03 Lab No. (for lab use) :
REQUESTOR INFORMATION
Name :
Post : MAKMAL KESIHATAN AWAM KEBANGSAAN
Address : KEMENTERIAN KESIHATAN MALAYSIA
District : State : Lot 1853, Kg Melayu Selangor,
Tel. No. : Fax No. : 47000 Sungai Buloh, Selangor Darul Ehsan
Email : Tel: 03-61565109 Fax: 03-614 02249 / 615 69654

Mycobacterium leprae VIABILITY & DRUG SENSITIVITY TEST REQUEST FORM
A. PATIENT INFORMATION

Name : Age : Date of Birth :
IC: Sex : Male Female
Your Reference No : Marital Status : Single Married
Address : Nationaltiy : Malaysian
Postcode : Non Malaysian
(Please state country of origin)
District : State : Occupation :
Tel No :
B. CLINICAL SUMMARY
Clinical Diagnosis : IDT TT BT BB BL LL

Type of Case : New Case Reactivation Relapse Problems in treatment
History : including complaints,any exposure to anti-leposy drug or family history of leprosy)

Previous Silt Skin Smear Report :
No Date BI MI

Site of Biopsy : Time & Date of Biopsy Procedure :

C.RESULTS (for laboratory use only) :

Verified By : ………………………

*IDT =Indeterminate leprosy, TT = Tuberculoid leprosy, BT = Bordeline tuberculoid leprosy
BB= Borderline borderline leprosy , BL= Borderline lepromatous leprosy, LL= Lepromatous leprosy

NB : Please send request form in duplicate
.

Buku Panduan MKAKB 90