This patient report form documents information for an individual seeking an individualized drug-resistant tuberculosis (DR-TB) treatment regimen. It includes the patient's name, demographic information, reason for submission, past medical history including HIV/ART details, TB history including previous drug exposures, clinical and laboratory findings, proposed DR-TB treatment regimen, and contact information for the responsible medical officer and dispensing pharmacist.

1. PATIENT REPORT FORM
CONSIDERATION FOR INDIVIDUALISED DR-TB TREATMENT REGIMEN
1
Version 2.1 dated 14_August_2015
NAME: CLINICAL FACILITY: DATE OF APPLICATION:
DATE OF BIRTH/AGE: FOLDER/HOSPITAL NUMBER: REFERRING DOCTOR:
GENDER: INPATIENT OR OUTPATIENT:
Reason for submission for individualized regimen (mark with an X):
(includes PTB and EPTB, regardless of HIV/ART status)
CASES FOR PROVINCIAL REVIEW CASES FOR NATIONAL REVIEW
Pre-XDR (Rif, INH, plus resistance to either an
injectable or a fluoroquinolone
Patients has already had > 3 months of pre-
XDR or XDR treatment
XDR (Rif, INH, injectable and fluoroquinolone
Patient has fewer than 2 of the following 4
drugs (plus one other drug) counted to be
effective in regimen:
a) injectable – only count if susceptible to
that injectable on DST (specimen taken
within last 3 months);
b) fluoroquinolone – only count if
susceptible to ofloxacin on DST
(specimen taken within last 3 months);
c) bedaquiline – do not count if exposed
to clofazimine for more than 2 months
previously;
d) linezolid – do not count if exposed to
linezolid previously for DR-TB.
MDR for drug substitution Age < 18 years
MDR with both inhA and KatG mutations Pregnant
MDR failure (failure to convert at 4-6 months or
confirmed reconversion at any point)
Other (describe):

2. PATIENT REPORT FORM
CONSIDERATION FOR INDIVIDUALISED DR-TB TREATMENT REGIMEN
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Version 2.1 dated 14_August_2015
PAST MEDICAL HISTORY (other than HIV and TB)
Details of cardiac abnormalities or other chronic diseases (include details of current medications and dosages, as
well as monitoring parameters to assess level of control):
HIV STATUS POSITIVE NEGATIVE
ART DETAILS
NEVER RECEIVED ART BEFORE
PREVIOUSLY ON ART ( BUT NOT NOW) Start date:
Reason for stopping:
Regimen: Stop date:
CURRENTLY ON ART
Regimen: Start date:
Latest monitoring results:
CD4:
Date:
VL:
Date:
HepB:
Date:
Further relevant details:
TB HISTORY
DETAILS OF PREVIOUS TB DRUG EXPOSURE:
Drug PZA EMB Kana Mfx Trd Eto INH Cm PAS Cfz LZD
Duration
of
exposure

3. PATIENT REPORT FORM
CONSIDERATION FOR INDIVIDUALISED DR-TB TREATMENT REGIMEN
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Version 2.1 dated 14_August_2015
CLINICAL FINDINGS:
CXR date:
Result:
Pregnancy test date:
Result:
ECG date:
QTcF:
Other findings:
SPUTUM MONITORING RESULTS
Date
GXP
RIF
Smear Culture
LPA
Rif
LPA
INH
inhA KatG
Phen
Ami
Phen
Cm
Phen
Ofx
Phen
Mfx
Geno
inj
Geno
FQ
Geno
Eto
BLOOD MONITORING RESULTS
Date Na+ K+ Creat GFR Mg2+ Ca2+ WCC Hb Plts ALT TSH

4. PATIENT REPORT FORM
CONSIDERATION FOR INDIVIDUALISED DR-TB TREATMENT REGIMEN
4
Version 2.1 dated 14_August_2015
PROPOSED DR-TB DRUG TREATMENT REGIMEN: Weight:
(delete if not applicable)
Drug Dosage Frequency Duration
BEDAQUILINE (BDQ) 400mg
then
200mg
daily
three times per
week
2 weeks
22 weeks
LINEZOLID (LZD)
As per guideline
PARA-AMINOSALCYCLIC ACID (PAS)
CLOFAZIMINE
TERIZIDONE
PYRAZINAMIDE (PZA)
ISONIAZID (INH)
ETHIONAMIDE (ETO)
ETHAMBUTOL (EMB)
KANAMYCIN
CAPREOMYCIN
LEVOFLOXACIN
PROPOSED ART REGIMEN: (If applicable)
OTHER CONCOMITANT MEDICATIONS:
OTHER RELEVANT INFORMATION:
RESPONSIBLE MEDICAL OFFICER :
Email address:
Tel: Fax:
Signature:
Date:
DISPENSING PHARMACIST:
Email address:
Tel: Fax:

5. PATIENT REPORT FORM
CONSIDERATION FOR INDIVIDUALISED DR-TB TREATMENT REGIMEN
5
Version 2.1 dated 14_August_2015