Addiction Treatment Tb Assessment/referrral Form

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ADDICTION TREATMENT TB ASSESSMENT/REFERRRAL FORM
PROGRAM:
COUNSELOR
PHONE:
CLIENT NAME:
REFERRAL DATE:
BIRTH DATE:
SEX:
M
F
RACE:
ADDRESS:
PHONE:
I. TB HISTORY (U=Unknown)
1.
Y
N
U
Previous history of tuberculosis Where?_________________________When?_______________
2.
Y
N
U
Previous positive TB skin test Where?__________________________When?_______________
(obtain documentation of positive results)
3.
Y
N
U
History of INH preventive therapy Where?______________________When?________________
If answers to questions 1, 2, or 3 are Yes, TB Skin Test not needed, STOP
4.
Y
N
U
History of negative TB skin test Where_________________________When?_______________
Retesting may be recommended 1 year following a negative test. Go to Section II.
II. TB RISK ASSESSMENT:
1.
Y
N
U HIV infection
2.
Y
N
Injection drug history
3.
Y
N
Are you aware of any exposure in last 24 months to someone close to you with active TB?
4.
Y
N
Female with crack cocaine history
5.
Y
N
Client enrolled in Methadone, Intermediate Care Facility or Therapeutic Community Program
If answer is “No” to 1, 2, 3, and 4, referral is not needed. STOP (Do not complete rest of form)
If answer is “Yes” to any of the above, go on to Section III.
III. REFERRAL INFORAMTION FOR TB EVALUATION
Name of TB Clinic:__________________________________________________________Appt. Date:______________
Address:__________________________________________________________Phone:__________________
Reason for Referral: 1. ____Client needs a TB skin test
2. ____ Client had a positive skin test _____mm on ____/____/____ and is in need of follow up
3. ____ Client meets the criteria for a TB suspect (TB Symptom Checklist) and needs immediate
evaluation.
Comments: _______________________________________________________________________________________
_________________________________________________________________________________________________
IV. FOLLOW-UP REPORT (to be completed by TB Clinic or Program Nurse)
1. _____ Client received skin test and had it read
Result _____mm
Pos
Neg
Date: ____/____/____.
2. ____ Preventive therapy was initiated on ____/____/____.
Next appointment is ____/____/____.
3. ____ Treatment for active TB was initiated on ____/____/____.
Next appointment is ____/____/____.
4. ____ Client had skin test and did not return for reading
5. ____ Client never kept appointment for TB screening
Comments:_______________________________________________________________________________________
_______________________________________________________________________________________________
Contact Person:____________________________________________Phone:_________________Date:______________
(TB Clinic: Please send form back to the above addictions program)
Declination Statement: I have been assessed as needing a TB skin test but have chosen not to have one even though I
realize that I am at risk of contracting the disease.
__________________________________________
Signature
Instructions for the TB screening form can be found on the ADAA web site at
Version 1 8/5

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