Virginia Department Of Health Tb Intake Sheet
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1Virginia Department of Health
TB Intake Sheet
WebVision #
ICD9#
Last Name___________
______ First Name
Middle
Birth Date
/ /
Race __
Sex
Marital status
Parent/Guardian _______________________
Home Address
Apt #
City
______
State
Zip
Home Phone
Work Phone:
Cell Phone ___________________
Country of Origin __________________ Year of arrival __________ Preferred Language _________________
Provider _________________________________
Provider Phone ______________________________
Reporting Source __________________________
Reporter Phone ______________________________
TB Symptoms
Site: __ Pulmonary __ Extrapulmonary(specify)__________
HIV Testing
(Check all that apply. May skip section
and complete Health History form if from patient interview)
Weight ________ Height ________
___ Not Tested
______None
___ Tested
Initial blood work?
Yes
No Report:
Yes
No
______Cough > 3 weeks
___ Negative
Yes No
LMP
EDD
BCG
______Productive? Y N
Hemoptysis? Y N
___ Positive
TST/IGRA Result
______Fever, unexplained
___ Results
Date Given _________ Date Read ________
______Unexplained weight loss
pending
Induration
mm
Positive
Negative
______Poor appetite
Date ___________
___ Borderline/Indeterminate (IGRA only)
______Night Sweats
______Fatigue
Current Chest x-ray
Date _______________
Other Info
Location of film: ___________ Addl. Old Films: Y N
Hospitalized: Y N
Additional Individual Risk for Infection
Negative
Abnormal
Cavitary
Where?
(Check all that apply)
Describe:
Room # ________
_______ Identified Contact (Case________________)
> 3 months in high prevalence country
Initial Bacteriology (Check for susceptibility if lab not DCLS)
_______ Resident/employee congregate setting
Date
Smear
Culture
Sensitivity
Medically underserved
Uses illegal drugs
Individual Risk for Progression to Disease
HIV infection
Medical conditions that increase risk
(diabetes, ESRD, Cancer, 10% below ideal
DOT
Self
Current Treatment Regimen
weight, etc.)
Drug
Dosage
Frequency
Start Date
Stop Date
History of inadequate TB treatment
Immunosuppressive therapy (steroids,
cancer treatment, include treatment for
Rheumatoid Arthritis such as Remicade,
Humira, etc.)
Additional Comments (additional treatment information, work site, school, living arrangements, other activities)
Class B Immigrant/Refugee?
Yes A # _____________________
Date __________
Completed by ____________________________________________
Clinician Orders
Clinician Assessment/Progress Notes
Isoniazid
_____ mg P.O.
Daily(7) Daily (5) BIW TIW
x _____ doses
Rifampin
_____ mg P.O.
Daily(7) Daily (5) BIW TIW
x _____ doses
Pyrazinamide
_____ mg P.O.
Daily(7) Daily (5) BIW TIW
x _____ doses
Ethambutol
_____ mg P.O.
Daily(7) Daily (5) BIW TIW
x _____ doses
Pyridoxine
_____ mg P.O.
Daily(7) Daily (5) BIW TIW
x _____ doses
Meds by DOT
Sputum collection protocol
Blood work Specify: _________________________________
Date _____________
Clinician Signature ________________________________________________
TB Intake: 2/2013
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