Form #3121-R - Tuberculosis Services printable pdf download

Tuberculosis Services

#3121-R (Rev. 01/2016)

 Suspect

 Case

 LTBI

 Presumptive LTBI

 B1/B2 Refugee or Immigrant

 MDR

Ryan White

 Child less than 5 years

Private Physician or Health Department:_________________________________________________________________________________________________

=========================== Refer to Report of Verified Case of Tuberculosis Instructions for Definitions ===========================

DEMOGRAPHICS

Name, Address, City, State, Zip, Phone

Date of Birth _____________________ Age_______

Sex at Birth _________________________________

Race _______________________________________

Hispanic or Latino Not Hispanic or Latino

Within city limits:

Yes

No

Pediatric (less than 15 years old):

Diagnosed at  Hospital  Physician’s Office

Country of Birth for Primary guardian__________________________________________________________

 Health Dept. Unknown

N/A

Name _______________________________________________ Phone ____________________________

Date reported to HD___________________________

Lived outside the U.S. for more than 2 months? Yes No  Unknown

Status at Diagnosis: Alive Dead

If yes, specify countries:____________________________________________________________________

Date of death _________________________________

Was TB a cause of death? Yes No Unknown

Immigration Status at 1

Entry to U.S.:  N/A (U.S. born)

 Immigrant visa

Family/Fiancé visa

U.S. born (born in 1 of 50 states, DC, U.S territories, or

 Student visa

Employment visa  Tourist visa

 Refugee

 Asylee or Parolee

to 1 parent of a U.S. citizen)

 Yes

 No

Other Immigration status

 Unknown

Country of Birth _______________________________

Foreign-born

 Yes  No

Any travel in the past 6 months?

 Yes

 No

If yes, country of birth __________________________

If yes, what countries (if outside the US) or states (if inside the US) and for how long: ___________________

Date entered U.S.______________________________

_______________________________________________________________________________________

Primary Occupation Within the Past Year:

Health Care Worker

Correctional Facility Employee

Migrant/Seasonal Worker

Retired Not Seeking Employment (student, homemaker, disabled)

Unemployed, but seeking employment

Other ______________________________

Unknown

Employer ______________________________ Last date worked ___________________ Return to work date___________________________

EVER a resident of a correctional facility?  Yes  No

If yes, year___________ ____ Location________________________________________________

Currently resident of correctional facility?

 Unknown

Yes

No

Federal Prison  State Prison

 Local Jail  Juvenile Correction Facility  Other Correctional Facility ___________________________________________

If yes, under custody of Immigration and Customs Enforcement (ICE)? Yes No

Resident of long term care facility?

 Unknown

EVER a resident of a Homeless Shelter?

Year______ Location ______________

Yes

No

Nursing home Hospital based Residential Facility Mental Health Residential Alcohol or Drug Treatment Other Long-term Care Facility__________

Homeless within past year Yes No Unknown

Depression

Low literacy

Yes No Unknown

Inadequate housing

Yes No Unknown

Suicidal/homicidal thoughts Yes No Unknown

Language barrier

Yes No Unknown

Inadequate income

Yes No Unknown

Paranoia

Yes No Unknown

Primary Language _________________________

Inadequate transportation Yes No Unknown

Defiant

Does not follow isolation

Yes No Unknown

Yes NoUnknown

Domestic violence

Erratic behavior

Misses appointments

Yes No Unknown

Yes NoUnknown

Child abuse

Yes No Unknown

Uncooperative

Yes No Unknown

Misses DOT appointments Yes NoUnknown

Reluctant to identify contacts Yes NoUnknown

MEDICAL HISTORY

HIV status:

Primary Care Physician ____________________________________________

Test Offered

 Yes  No

Ever diagnosed with or treated for:

Refused Testing

 Yes  No

Diabetes Mellitus Cancer (site) __________________________________

Test done

 Yes  No

Asbestos Exposure

Leukemia

Lymphoma

Hodgkins

Silicosis

Results:

Asthma

Bronchitis

Chest injury

Chest surgery

COPD

Indeterminate

End Stage Renal Disease

Chronic liver disease

Tumor necrosis factor alpha (TNF) antagonists

Organ Transplant

Unknown

Status Negative

Corticosteroid Therapy

Other immunosuppression (not HIV/AIDS

Status Positive  CD4 _________

Hypertension

Heart disease

Bleeding

Gastrectomy

Intestinal Bypass

On Antiretrovirals  Yes  No

Malabsorption syndrome

 Arthritis

Bone/Joint disorder

If Yes, List:

Hepatitis B : Yes  No

Test ordered  Yes  No

Hepatitis C: Yes No

Test ordered  Yes No

PCP Prophylaxis  Yes  No

Ever received BCG vaccine?  Yes

 No

 Packs of cigarettes smoke daily __________

Females Only:

 Ounces of beer drinks daily ____  Ounces of wine drank daily ____  Ounces of liquor drank daily ____

Last menstrual period ________________________

Injecting drug use ______________________ Non-injecting drug use_____________________________

Contraceptive Method:

 Other _________________________________________________________________________________

Pregnant?

 Yes  No

Recent hospitalization, specify details:___________________________________________________________

Pregnancy test done?  Yes  No

_________________________________________________________________________________________

Breastfeeding?

 Yes  No

Medical Complications:

TB Symptoms present:

Normal weight (lb/kg)__________

Current (initial) weight (lb/kg)_______________

 Cough

 Weight loss

Height: __________________

BMI: ______________________

 Night sweats

Allergies:__________________________________________________________________________________

Fatigue

 Fever

 Hemoptysis

_________________________________________________________________________________________

Current Medications:________________________________________________________________________

_________________________________________________________________________________________

GA DPH TB Unit

Form 3121-R (Rev. 01/2016)

Form #3121-R - Tuberculosis Services

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