Place of Work:
School Attended:
2
Site of TH
SALIUM
Dupcial
Boru Chak seos 10
(1 maty) 2
Rep, System.
Poaldive
On TrexineCNC) ||
Membres
Neithe
Da ObservaUJO
Bone & Job
Walkowa
Keletred
Ober00
Dbed
FORM 2,
3
QUARANTINE AND PREVENTION OF DISEASE ORDINANCE.
PREVENTION OF THE SPREAD OF INFECTIOUS Diseases REGULATIONS.
NOTIFICATION OF INFECTIOUS DISEASES OTHER THAN TUBERCULOSIS.
Name
Addres!
Does patient have a history of past treatment for
tuberculosis?
Ya
No
If yes, please state the YEAR in which he first
received treatment:
Place of Work:
Notified under the Prevention of the Spread of Infectious Diseases
Regulations by
(Sabarkung auf Montvine Degerl
NAME in
BLOCK LETTERS
(PLEASE DELETE whichever is not applicable:}
"I will arrange for examination of contacts
myself."
"Please arrange for examination of contacts to be
done by the Government Chest Service."*
Further Remarks:
Name
Address
School Attended:
For office we
No. Character
Sex
Age
19.......
Dischse
(hate of Nonileon) out!
Suspected Confirmed
On
19
Hospital sent to (if any)
For Official Use
If a case of malaria,
DUPLICATE (Tuberculosis Notification)
Date of Notification
(a) Recurrent or fresh case?
(b) Vivax, Calciparum or malariae infection.
(c) Has the patient bad malaria before?
(d) When was the last attack?
(e) Has the patient been outside the Urban Arce (ie. Hong Kong Island, Kowloon and New Kowloon) recently? If so, where and when?
Notified under the Prevention of the Spread of Infectious Diseases Regulations by
19.......
Remarks:
(Sigmarine of Medfying Doctor)
Mame (in Black fetigra)
TOLD HERE
(Dan)
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