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(1)

(2)
Date of
S.No admission
(DD/MM/YY)

(3)
MRN
YEAR 200____

(4)
Personal Identification

Name

Father , Grandfather Name

(5)
Age

(6)
Sex
(M/F)

(7)
Woreda/ Kebele
Address

(8)
case )
Country
( imported

(9)

Travel Histroy (Y/N)

No of Months sick before


(10)

admission

Pregnancy
Trimester
(11)

(Y/N/NA)
Primary ( ü )
Relapse ( ü )
VL

PKDL

New ( ü )
CL
Diagnosis

Relapse ( ü )
New ( ü )
MCL

Relapse ( ü )
DAT(P/N/BL)
LEISHMANISES REGISTER

RDT(P/N)
Lab Result

Aspirate(0-+6)
(12) (13) (14) (15) (16) (17) (18) (19) (20) (21)

Nutritional Status
(22)

(Normal, MAM ,SAM)

Conc-omitant OI

Drug Side Effect

Treatment Regimen
(23) (24) (25)

Initial treatment
(26)

outcome
VL (Viseral Leishmaniasis)

Confirmation of
(27)

cure(C/P)

Date of Discharge
(28)

(DD/MM/YY)

Skin test result (P/N/In)


(29)

Size of Lessions
(30)

(<4cm, >4cm)
Time elapsed (in days)
(31)
CL (Cutaneous Leishma
Conc-omitant OI - Drug Side Effect - VL Regimen code CL Regimen code
Column 23 Column 24 -Column 25 Column 32
1.Tuberculosis, 1.Cardiotoxicity, 1=SSG+PM, 1=Megilumine
2=SSG, Antimoniate
2.Pneumonia, 2.Pancrearatitis 3=Ambisome , (glucantime),
3.Nephrotoxicity, 4=Ambisome + 2=SSG,
3.Skin infection, Miltefosine 3=Other Specify
4.Hepatotoxicity,
4. Sepsis 5. Others
5.Others…….. 6. Unknown
Treatment Regimen

(32)
(33)
Date of
Discharge
(DD/MM/YY)
Initial treatment
CL (Cutaneous Leishmaniasis)

outcome
HIV test offered (√)

HIV test performed (√)


PITC

(34) (35) (36) (37)


(38) HIV Test results (R/NR)
Remark
CL Regimen code -
Column 32
1=Megilumine
Antimoniate
(glucantime),
2=SSG,
3=Other Specify