Report of New or Reactivated Case - Northwestern Health Unit

Patient information

Please include all currently known information.

Name

Date of birth

Gender

Male
Female

Address

Phone number

City/Town

Postal code

Health card number

School

Workplace

Country of birth

First nation origin

Yes
No

Living on reserve

Yes
No

Diagnostic information

Date of onset

Date of diagnosis

Active

Reactive

Site

Organism

Type of specimen

Confirmed by

Smear
Culture
X-ray

Smear confirmation date

Culture confirmation date

X-ray confirmation date

Name of hospital

Date admitted

Date discharged

Symptoms

Risk factors

Medications and dates started

Additional information

Clinical progress

Ongoing
Resolved
Deceased

Date of death

Drug resistance

Please indicate the name of the medication

Completed by

Facility

All residents of Ontario are entitled to free medication for treatment of Tuberculosis and INH chemoprophylaxis. Medication is available from the Northwestern Health Unit. Please fax the prescription NWHU at 1+807-468-3813.

Personal information is collected under the authority of the Health Protection and Promotion Act and related legislation and in accordance with the Personal Health Information Protection Act and/or the (Municipal) Freedom of Information and Protection of Privacy Act. We collect only the personal information needed to provide public health programs and to plan and evaluate our services. Your information may be shared with others as required or permitted by law. For more information contact the health unit at 800-830-5978 or see the privacy statement on our website at www.nwhu.on.ca.