Early Detection of Tuberculosis (TB) 
Ask if Patient has any of these symptoms 

* If "Yes" is selected for any one of the questions below with "*" then show a pop-up message "Refer to the nearest health facility and collect the Sputum sample". 
Show these beneficiaries to 'Referral list module in the Home' section 

** If "Yes" is selected for any one of the questions below with "**" then show a pop-up message "Refer to the nearest health facility and collect the Sputum sample". 
Show these beneficiaries to 'Referral list module in the Home' section 

Date 

Calendar 
Date Picker 

Is Mandatory 

• Default value Today's Date 

• Not greater than Today's Date 

• Accept date greater or equal to Date of beneficiary registration 

• should not allow to update in edit or once submitted 

Name 

Textbox 

Auto fill from Beneficiary details 
Show: First Name + Last Name 
Read only 

Age 

Textbox 

Auto fill from Beneficiary details 
Read only 

Sex 

Textbox 

Auto fill from Beneficiary details 
Read only 

Coughing More than 2 weeks * 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Blood in Sputum * 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Fever > 2 weeks * 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Rise of fever in evening

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Loss of Appetite 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Loss of Weight * 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Night Sweats * 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

History of TB * 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Are you currently taking Anti TB drugs ** 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Inform to ANM / MPW/ MO for tracing of Family members 

Anyone in Family Currently Suffering from TB ** 

Spinner 

Is Mandatory 
Choose: 

• Yes 

• No 

Inform to ANM / MPW/ MO for tracing of Family members 

Submit 

Button