Tuberculosis Treatment Plan Form
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1
2New York City Department of Health and Mental Hygiene
Bureau of Tuberculosis Control
TB TREATMENT PLAN
This form must be submitted to Department of Health and Mental Hygiene (DOHMH) within one month of initiating treatment
Please complete form in entirety and return to patient case manager or fax to case manager (_____)_____-______
SECTION A: Patient Information (To be filled out by DOHMH staff)
Patient Name:
DOB: _____/____/______
Street:______________________________________City:___________________State:_____Zip: _____________
SECTION B: Provider Contact Information (To be filled out by DOHMH staff)
Provider assuming responsibility for TB care:____________________________________________________
Provider address:_________________________________________ Tel. (_____) ______-__________
Street:______________________________________City:___________________State:_____Zip: _____________
SECTION C: Clinical Information
Susceptible
Resistant
No results
Susceptible
Resistant
No results
Isoniazid
Ethambutol
(INH)
Susceptible
Resistant
No results
Susceptible
Resistant
No results
Rifampin
_________
Susceptible
Resistant
No results
Susceptible
Resistant
No results
Pyrazinamide
_________
HIV testing performed? Yes No, If no, reason______________________________________________________
List current medications other than for TB ______________________________________________________________
SECTION D: Treatment Regimen
Treatment start date:______/_____/20______
Estimated treatment completion date: _______/____/20____
Planned treatment duration: 6 months 9 months
12 months
Other duration. Reason: ____________________
Planned TB Treatment Regimen
Duration
Drug
Dose(mg)
Duration (months)
Other anti-TB drugs
Dose(mg)
(months)
Isoniazid (INH) ____________
______________
__________________
____________
____________
____________
______________
____________
____________
Rifampin
__________________
Pyrazinamide
____________
______________
__________________
____________
____________
____________
______________
____________
____________
Ethambutol
__________________
TB drug frequency: daily 2x weekly
3x weekly
other____________________________________________
Patient on directly observed therapy (DOT)? Yes No If no, state reason_______________________________________
DOT Provider name:_______________________________________ Tel. (_____)______________________________
Signature of provider assuming TB care: __________________________ License Number: ___________ Date:
/
/ 20
HEALTH DEPARTMENT REVIEW
DOHMH ref no.___________________________
DOHMH Physician Comments/Issues_______________________________________________________________
Plan discussed with provider YES NO________________________________________________________
Reviewed by: _____________________________________________
_______/____/20____.
(Name of DOHMH Physician)
Note: Note: This form does not replace the Report of Patient Services form (TB 65) which must
also be submitted to the Health Department for every monthly visit of patients with active
tuberculosis
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