Form 3142 - Follow-Up Report On Patient With Tb

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Follow-up Report on Patient with
Tuberculosis (TB)
Date_________________________
Physician____________________________________________
Patient________________________________________________
Address_____________________________________________
Address_______________________________________________
____________________________________________________
______________________________________________________
Telephone___________________________________________
DOB_____________ Telephone____________________________
“Treatment of tuberculosis benefits both the community as a whole and the individual patient; thus, any public health program or private provider
(or both in a defined arrangement by which management is shared) undertaking to treat a patient with tuberculosis is assuming a public health
function that includes not only prescribing an appropriate regimen but also ensuring adherence to the regimen until treatment is completed
(ATS/CDC/IDSA: Treatment of Tuberculosis, 2003).”
Since tuberculosis is a communicable disease, the County Public Health Department is required by law to assure that every tuberculosis patient
receives proper treatment and follow-up. Please provide us with the most recent information available on the above identified patient. To keep
medication orders accurate, please list and date current medication order, any dosage changes, or when medications have been discontinued as
listed below. In order to comply with Georgia Statues your cooperation is necessary in completing, signing and returning this form to the County
Public Health Department by______________________________ .
X-RAY FINDINGS:
BACTERIOLOGIC STATUS:
Date____________________________________
Date __________________________________________________________
Normal _________________________________
Type of Specimen _______________________________________________
Abnormal _______________________________
Smear: Pos _____________ Neg _____________ Not Done _____________
Cavitary ________________________________
Culture: Pos _____________ Neg _____________ Not Done _____________
Non Cavitary ____________________________
Culture Pending _________________________________________________
Stable __________________________________
Last Negative (Date) _____________ # of Negative Cultures Since Last Positive______
Worsening ______________________________
Last Positive (Date)_______________________________________________
Improving ______________________________
If positive please specify:
M.Tuberculosis ___________ Other Mycobacteria _______________
Drug Susceptibilities Ordered? Yes______ (Attach Copies)
No _________
CLINIC/LAB RESULTS:
Date
Results
Date
Results
AST/SGOT
_________
______________
Vision
___________
_______________
Hearing
_________
______________
Color
___________
_______________
__________
_________
______________
____________
___________
_______________
CURRENT CHEMOTHERAPY STATUS:
Date__________________________________________________________
Total # Doses
Medication
Date Started
Discontinued
Reason
Given to Date
Isoniazid
__________
____________________
___________
_____ mg PO
___ X wk _____________
Rifampin
___________
__________
____________________
___________
_____ mg PO
___ X wk
Ethambutol
___________
__________
____________________
___________
_____ mg PO
___ X wk
Pyrazinamide
___________
__________
____________________
___________
_____ mg PO
___ X wk
Pyridoxine
___________
__________
____________________
___________
_____ mg ___
___ X wk
___________
__________
____________________
___________
______________
_____ mg ___
___ X wk
______________
_____ mg ___
___ X wk _____________
____________
_______________________ _____________
Name of Person doing Directly Observed Therapy _________________________ or DOT sheet is attached ____________
COMMENTS: (Please use reverse side of page if necessary.)
________________________________________________________
______________________________________
Physician’s Name
Date
Please address your response:
Attention ___________________________________________________M.D./P.H.N.
Address _____________________________________________________________
_____________________________________________________________
GA DPH TB Unit
Form 3142 (Rev. 12/2011)

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