Form 3141 - Initial Report On Patient With Tb printable pdf download

Initial Report on Patient with

Tuberculosis (TB)

__________________________________________

Physician_________________________________________

Date

Address

________________________________________

Patient’s Name ______________________________________________

________________________________________

Address ____________________________________________________

Telephone ________________________________________

DOB ____________________ Telephone _________________________

The above identified patient suspected/diagnosed as having tuberculosis has given your name as his/her attending physician. Since tuberculosis is a

communicable disease, the County Public Health Department is required by law to assure that every tuberculosis patient receives proper treatment,

follow-up supervision and contact investigation. In order to comply with Georgia Statues and to assure quality care for this patient, your cooperation in

completing, signing and returning this form is necessary. This form is due to the County Public Health Department by ______________________.

NEW TB CASE? YES ________ NO ___________

OLD CASE REACTIVATED? YES __________ NO ___________

TUBERCULOSIS STATUS

SKIN TEST RESULTS

X-RAY FINDINGS

BACTERIOLOGICAL STATUS

Date____________

Date_______________________

Date______________________________________________

Not Done _______

Normal ____________________

Type of Specimen___________________________________

Mantoux _____ mm

Abnormal___________________

Smear: Pos__________ Neg__________ Not Done________

Tine_________ mm

Cavitary____________________

Culture: Pos_________ Neg__________ Nor Done________

Noncavitary ________________

Pending ___________________________________

Stable _____________________

If positive please specify:

M. tuberculosis_____________________

Worsening _________________

Improving _________________

Other mycobacteria _________________

LOCATION OF DISEASE

CLINICAL/LAB RESULTS

CHEMOTHERAPY STATUS

Date

#Doses Given

Pulmonary _______

Date ______________________

Medication

Started

To Date

Pleural __________

AST/SGOT _________________

Isoniazid

_____ mg PO

___ X wk ___________

_________

Lymphatic _______

Rifampin

_____ mg PO

___ X wk ___________

_________

Bone or Joint _____

Date ______________________

Ethambutol

_____ mg PO

___ X wk ___________

_________

Genitourinary _____

Visual Acuity _______________

Pyrazinamide

_____ mg PO

___ X wk ___________

_________

Miliary ___________

Color Discrimination _________

Pyridoxidine

_____ mg ___

___ X wk ___________

_________

Meningeal ________

__________________________

______________

_____ mg ___

___ X wk ___________

_________

Peritoneal ________

Date ______________________

______________

_____ mg ___

___ X wk ___________

_________

Other (Specify)____

Hearing ___________________

None _________

Reason_________________________________________

CONTACT FOLLOW-UP

I have already tested the contacts of the above named patient and will complete and return the enclosed contact form. ___________________

I prefer that the County Public Health Department provide contact investigation and follow-up. ___________________________________

MEDICAL CARE

“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).” Please indicate who will provide the following (PMD = Private Medical Provider / HD = Health Department):

PATIENT CARE

PMD _____ HD _____

CHEST X-RAY

PMD_______HD_____

TB MEDICATION*

PMD______HD______

AST/SGOT

PMD_______HD_____

SPUTUM EXAMINATION

PMD______HD______

HEARING

PMD_______HD_____

OTHER SPECIMEN (Specify)

PMD______HD______

VISUAL ACUITY/COLOR

PMD_______HD_____

BLOOD WORK (Specify)

PMD______HD______

DIRECTLY OBSERVED THERAPY**

PMD______HD______

Date of patient’s next appointment with you: ______________

If the Health Department provides TB Medications to the client, a monthly assessment MUST be done by the Health Department provider.

**PLEASE NOTE: Directly Observed Therapy is the standard of care for all patients suspected/diagnosed as having TB in Georgia.

In the event you prefer to provide the above services yourself, a follow-up form will be sent to you every month to obtain patient status and contact

data. In this manner, the County Public Health Department will fulfill its obligation in assuring that this patient and his/her contacts are receiving

adequate care. Be assured that all information provided will be held in confidence and used for official purposes only.

Physician’s signature _______________________________________________ Date ______________

Please address your response:

Attention: _________________________________________________________________M.D./P.H.N.

Address _____________________________________________________________________________

GA DPH TB Unit

Form 3141 (Rev. 12/2011)