Community-Based TB Care: Experience from ... - CORE Group

Community Based TB care through former TB patients’ social clubsAnnex 3: Referral form to be used by traditional healersP.O. Box 45232Dar es Salaam Tanzania East AfricaTel: 022 -2856512 mob: 0756 - 934750, 0784 – 505637email: MUKIKUTE@yahoo.ca.MPANGO WA TAIFA WA KUDHIBITI KIFUA KIKUU NAUKOMA.27/OCT/2009FOMU YA RUFAA KUTOKA KWA MGANGA WA JADI/TIBA MBADALA.Jina la mgonjwa…………………………………………………………………………Umri………….Siku……………Mwezi………….Mwaka…………….Mahali anapoishi mgonjwa, Wilaya………………Mkoa…………………………….Namba ya nyumba…………………………………Jina la Mjumbe/Mwenyekiti wa Serikali za Mtaa………………………..........................Sababu ya rufaa: Kifua Kikuu/Mengineyo……………………………………………Anatumwa kwenda kituo cha tiba cha……………………….tarehe…………………….Tarehe mgonjwa alipofika Kwa mganga wa jadi…………………………………………Jina la mganga wa jadi/tiba mbadala………………………………………………………Anwani……………………………………………………………………………………..MarejeshoJina la mganga wa jadi…………………………………………………………………….Anwani………………………………Namba ya simu……………………………………Jina la mgonjwa……………………………….tarehe ya kupokelewa……………………..Matokeo ya uchaguzi……………………………………………………………………..Jina la Mratibu………………………………………………………................................. NB: Mgonjwa aonane na Mratibu wa Kifua Kifua Kikuu na UkomaExperience from Temeke Page 22