Scribd
Upload
169 views1 page

PMDT Request Form

The document is a requisition form for the National TB Control Program's Programmatic Management of Drug-resistant Tuberculosis, specifically for Tarlac Provincial Hospital for the second quarter of 2025. It details the treatment regimen for a patient, including the required quantities of various medications. The form includes calculations for total daily consumption, monthly and quarterly requirements, and the quantity requested based on stock-on-hand.

Uploaded by

Angela niña Bañaga
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
169 views1 page

PMDT Request Form

The document is a requisition form for the National TB Control Program's Programmatic Management of Drug-resistant Tuberculosis, specifically for Tarlac Provincial Hospital for the second quarter of 2025. It details the treatment regimen for a patient, including the required quantities of various medications. The form includes calculations for total daily consumption, monthly and quarterly requirements, and the quantity requested based on stock-on-hand.

Uploaded by

Angela niña Bañaga
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

National TB Control Program

Programmatic Management of Drug-resistant


Tuberculosis (PMDT)
Treatment Site Requisition Form
Name of Treatment Site/ Partner: TARLAC PROVINCIAL HOSPITAL Request for the 2ND Quarter of 2025
Year
Name of MHO/ CHO/ PHO: Date prepared: 04/22/2025

Name of Treatment Facility: TARLAC PROVINCIAL HOSPITAL Prepared by: ANGELA NIÑA E. BAÑAGA

Treatment regimen of patient: number of units in daily dose


drug H R Z E K Cm Lfx Lzd Mfx Pa Cs PAS CFZ BDQ B6
Name of patient m
strength m mg 500mg 400mg g g 500mg 600m mg m mg g 100mg 100mg 50mg
g g g
unit tablet capsule tablet tablet vial vial tablet table tablet tabl capsule sachet tablet
t et

DELOS REYES ESTEBAN 1 1 1 2

Total daily consumption a 1 1 1


2 TABS
MWF
Monthly b = a x 26 30 30 30 24
Quarterly c=bx3 90 90 90 72
Quarterly + 1 month buffer d=c+b 120 120 120 96
Stock-on-hand e 0 0 0 0

Quantity requested f=d-e 90 90 90 72


Note: Please accomplish in triplicate copies. (1- TS, 1- CHO/ PHO, 1- S/TC)

You might also like