Form Tb-101 - Latent Tuberculosis Infection Record - West Virginia Department Of Health And Human Resources

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West Virginia Department of Health and Human Resources 
Division of Tuberculosis Elimination 
LATENT TUBERCULOSIS INFECTION RECORD 
 
 
INITIAL REPORT ________ FINAL REPORT ___________
 
LAST NAME: _________________________FIRST NAME: ______________________MI:_____     Birth Date: ____/____/_______ Age: ___________ 
PHONE: (___) ____________ ADDRESS: ____________________________CITY:_________________COUNTY:___________STATE:____ ZIP: ______ 
SEX 
RACE 
ETHNICITY 
REASON FOR TESTING 
RESIDENCE 
COUNTRY OF BIRTH 
____WHITE 
SCREENING FOR: 
___PRIVATE  RESIDENCE 
 
____HISPANIC 
___USA 
___LOW RISK      ___HIGH RISK 
___HOMELESS 
____ASIAN OR PACIFIC ISLANDER 
________MALE 
____NON‐HISPANIC 
___OTHER (SPECIFY) 
___WORK REQUIREMENT 
___SHELTER 
____BLACK 
 
___SYMPTOMS/DIAGNOSTIC 
___JAIL/PRISON 
____UNKNOWN 
__________________ 
____AMERCIAN INDIAN 
___CONTACT TO TB CASE 
___NURSING HOME 
________FEMALE 
 
IF OTHER, DATE OF ENTRY TO US: 
____OTHER____________
___MIGRANT WORKER 
___TREATMENT CENTER 
______/______/_____________ 
___IMMIGRANT/REFUGEE
___OTHER_________________ 
 
DIABETES 
CHEMICAL USE 
HIV STATUS 
LUNG 
GI/GU 
CANCER/CHEMO 
HEPATITIS 
MEDICATIONS 
DISEASE 
____NONE KNOWN 
____NONE KNOWN 
____UNKNOWN 
____NONE KNOWN 
____NONE KNOWN 
____NONE KNOWN 
____NONE KNOWN 
____NONE KNOWN 
____
INJECTED DRUG ABUSE 
____DIET ONLY 
____NEGATIVE 
____ASTHMA 
____GASTRECTOMY 
____LEUKEMIA 
____HEP A 
____STEROIDS 
____OTHER DRUG ABUSE 
____ORAL MEDICINES 
____POSITIVE 
____SILICOSIS 
____WT.LOSS SURGERY 
____LYMPHOMA 
____HEP B 
____TNF INHIBITORS 
 
____INSULIN 
DATE:_________ 
____PNEUMONIA 
____RENAL DISEASE 
____OTHER MALIGNANCY 
____HEP C 
____ANTICONVULSANT 
____EXCESS ALCOHOL 
____UNCONTROLLED 
TEST OFFERED: 
____OTHER 
____CIRRHOSIS 
____IMMUNOSUPPESSIVE TX 
____UNKNOWN TYPE 
____TRANQUILIZER 
 ____>2 DRINKS/DAY 
 ____BINGE DRINKING 
____YES ____NO 
_________________ 
 
____OTHER 
____BIRTH CONTROL 
 
 
____PREGNANCY 
________________________ 
____ANTICOAGULANT 
____CURRENT TOBACCO 
IF NO, REASON 
EDD:____/____/____ 
____OTHER_________ 
 
AMOUNT_____________
NOT OFFERED: 
____POST PARTUM 
____ALLERGIES 
_______________ 
 
  
PRIOR TB THERAPY 
SYMPTOMS 
SKIN TEST RESULTS 
IGRA RESULTS 
CHEST X‐RAY 
____NONE 
____NONE 
TST #1 
#1 TYPE _______________ 
DATE:_____/_____/_____ 
____POST PREVENTIVE THERAPY (PT) 
____PRODUCTIVE COUGH 
DATE:____/____/____  
DATE:____/____/______ 
 
____PARTIAL PT 
____HEMOPTYSIS 
READING________MM 
____POSITIVE 
____NORMAL 
____UNDERGOING PT 
____SHORT OF BREATH 
 
____NEGATIVE 
         ____WITHIN NORMAL LIMITS 
____POST BCG, YEAR________ 
____WEIGHT LOSSS 
TST #2 
____INDETERMINATE 
         ____ABNORMALITY LIMITED TO CALCIFIED GRANULOMA(S) 
 
____NIGHT SWEATS 
DATE;____/____/____ 
 
 
____MULTI‐DRUG TX FOR ACTIVE TB 
____FEVER 
READING________MM 
#2 TYPE _______________ 
____ABNORMAL 
YEAR____________ 
____MALAISE 
 
DATE:____/____/______ 
        ____POSSIBLE PRIMARY TB 
____CURRENT WT:_______ 
KNOWN POSITIVE REACTOR 
____POSITIVE 
         ____EVIDENCE OF OLD INACTIVE TB 
____OTHER_____________ 
_______MM   YEAR;_____ 
____NEGATIVE 
         ____SUSPECT ACTIVE TB 
 
____INDETERMINATE 
 
LAST KNOWN NEGATIVE TEST 
 
____OTHER 
DATE____/____/____ 
SEND ALL ABNORMAL CXR’S TO WVDTBE 
 
REASONS FOR 
ANTI‐TB DRUGS 
DURATION 
PREVENTIVE THERAPY 
STOPPED PREVENTIVE THERAPY 
PREVENTIVE THERAPY 
____CONTACT, RECENT 
____ISONIAZID (INH) 
____2 MONTHS 
 
____COMPLETED THERAPY        ____LOST 
____REACTOR 
____RIFAMPIN (RIF) 
____12 WEEKS 
START DATE:____/____/______ 
____REFUSED                                ____DIED 
____CONVERTOR 
____RIFIPENTINE (RPT) 
____4 MONTHS 
 
____ACTIVE TB                              ____NOT INFECTED 
____OLD TB DISEASE 
 ____OTHER 
____6 MONTHS 
 
____MOVED                                   ____OTHER 
____OTHER HIGH RISK 
______________________ 
____9 MONTHS 
 
____ADVERSE REACTION             _________________ 
_________________ 
____OTHER 
STOP DATE____/____/____ 
 
_____________ 
MONTHS ON THERAPY________ 
 
____NOT RECOMMENDED 
____REFUSED 
 
CONTACT INVESTIGATION/INDEX CASE 
REPORTING INFORMATION 
LAST NAME_________________________________________________
PERSON REPORTING
FIRST NAME________________________________________________ 
_______________________________________________________ 
DOB________/________/________ 
 
DATE TB DIAGNOSED________/________/________ 
FACILITY OR LOCAL HEALTH DEPARTMENT 
 
_______________________________________________________ 
_____UNKNOWN INDEX CASE 
 
 
DATE OF REPORT_______/_____/___________ 
COMMENTS: _____________________________________________________________________________________________________________ 
________________________________________________________________________________________________________________________ 
TB‐101 07/01/2014 
 

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