12-Dose Isoniazid-Rifapentine Latent Tb Infection Treatment Dose And Symptom Monitoring Log

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Patient Name: ____________________________ County: _______________________
BASIC INFORMATION LOG: 12-Dose Isoniazid-Rifapentine Latent TB Infection Treatment Dose and Symptom Monitoring
Patient ID: ____________ Age:________ Sex: M / F Ethnicity: Hispanic / Non-Hispanic
Race: ______ Weight: ________lbs Height: ______ft/inches
Treatment reason: ☐Contact
☐Corrections
☐Homeless
☐Refugee
☐Foreign-born
☐Convertor
Dose: INH ______mg RPT______mg
*Check
symptoms or events reported on the listed date; otherwise, leave blank.
Date:
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
__/__/__
0
Dose:
2
3
4
5
6
7
8
9
10
11
12
1
Baseline
Directly Observed Therapy
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(DOT) received
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No adverse reaction
Loss of appetite
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Nausea or vomiting
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Yellow eyes or skin
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Diarrhea
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Rash/hives
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Fever or chills
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Sore muscles or joints
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Numbness or tingling
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Fatigue
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Dizziness/fainting
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Abdominal pain
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(Other)______________
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Treatment stopped or held
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(complete AE report on next page)
Final Disposition: ☐ Completed INH-RPT treatment
☐ Stopped INH-RPT treatment
Date __/__/__
☐ Lost to follow-up
☐ Moved
☐ Other
☐ Adverse event
(fill out next page if treatment stopped for AE)
☐ Pending Completion of Alternate Regimen

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