HIV referral report form International

HIV referral report form International

Nation

Refer from

Department

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HIV referral report
Forwarding report for HIV infected persons

	Title	Total	Burmese	Laos	Cambodian	Chinese	Vietnamese	Thai
	1. Number of patients referred	361	318	30	11	1		1
	1.1 Gender
	1.1.1 Male	156	140	10	6
	1.1.2 Female	205	178	20	5	1		1
	1.2 Age
	1.2.1 0-20	18	16		2
	1.2.2 21-40	214	183	23	7	1
	1.2.3 41-60	123	114	6	2			1
	1.2.4 Age 61 and over	6	5	1
	2. Number of accepted patients from the destination hospital	148	141	6		1
	3. Number of cases HIV with TB transmitted	13	12	1
	4. Number of people screened for tuberculosis	177	150	20	6			1
	5. Hospital that accepts forwarding
	5.1 Number of deliver	361	318	30	11	1		1
	5.2 Receiving number	148	141	6		1


Forwarding report for HIV infected persons

	Nation	Refer	Receive	Screen TB
	Total	361	148	177
	Burmese	318	141	150
	Cambodian	11	0	6
	Chinese	1	1	0
	Laos	30	6	20
	Thai	1	0	1

	Receive Name	Total
	Total	148
	Bokeo Hospital	4
	Savannakhet Hospital	2
	Tachileik	142