Tuberculosis Disease Initial Request For Medication
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4DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Public Health
s. 252.10 (7), Wis. Stats.
F-44000 (Rev. 05/2016)
Wisconsin Tuberculosis Program
Telephone: (608) 261-6319
TUBERCULOSIS DISEASE
FAX: (608) 266-0049
Page 1 of 2
INITIAL REQUEST FOR MEDICATION
Fields marked with an (*) asterisk are required. Please complete patient information on reverse side.
Submit completed form to the Local Health Department.
Submit completed
Local Health Department
Fax Number
form to:
*NAME –Patient (Last, First, Middle Initial)
*Date of Birth (mm/dd/yyyy)
*Address (Street or Rural Route)
*Telephone Number
*City
*Zip Code
*County
Other contact, as needed
*Sex
*Race
*Ethnicity
*Weight
*Prescription Insurance Provider & Insurance No.
Hispanic
Non-Hispanic
*NAME – Clinician
NAME - Hospital/Clinic/Facility
*Address (Street, City, State, Zip code)
*Telephone Number
*MEDICATION ORDERS
(Check mg/kg for patients with variable weight)
Medication
Dose
Frequency
Duration of Therapy
300 mg
mg
mg/kg
Daily
Other
6 mo
9 mo
Other
Isoniazid (INH)
10-15 mg/kg infants + children; 5 mg/kg up to 100 lb/45.5 kg adults; 300 mg maximum daily all others
Rifampin
600 mg
mg
mg/kg
Daily
Other
6 mo
9 mo
Other
10-20 mg/kg infants + children; 10 mg/kg up to 100 lb/45.5 kg adults; 600 mg maximum daily all others
800 mg
1200 mg
1600 mg
Ethambutol
Daily
Other
2 mo
6 mo
Other
mg
mg/kg
20 mg/kg infants + children; 40-55 kg, 800 mg; 56 – 75 kg, 1200 mg; 76 – 90 kg, 1600 mg; long term EMB=15mg/kg
1000 mg
1500 mg
2000 mg
Pyrazinamide
Daily
Other
2 mo
6 mo
Other
mg
mg/kg
30-40 mg/kg infants + children; 40 – 55 kg, 1000 mg; 56 – 75 kg, 1500 mg; 76 – 90 kg, 2000 mg; long-term PZA=25mg/kg
Vitamin B6 (pyridoxine)
Daily
Other
9 mo
Other
10 – 50 mg/day when on INH
Multivitamin
Daily
Other
9 mo
Other
To include Vitamin D ≥ 400 IU (10 mcg) for infants 0 – 12 months, 600 IU (15 mcg) for children and adults; for the duration of the prescription.
Other:
Other:
Standard of care: All medications are given together under directly observed therapy (DOT). Medications are administered seven
(7) days per week for at least the first two weeks of therapy. Then medications may be administered five (5) days per week by DOT,
with the remaining two doses self-administered over the weekend. Medications for those expected to gain weight during therapy are
written as mg/kg; the nurse will weigh the person weekly and drug dosage will be adjusted to maintain the mg/kg dose as closely as
can be measured. Adjustments to dose, frequency, and duration of therapy are common and depend upon the individual patient’s
disease and response to therapy.
MONITORING ORDERS
1. Beginning with the third week of therapy, collect one sputum sample weekly and send to WSLH for smear and culture.
2. Assess the patient at least weekly for side effects and medication toxicity. Hold medications and call clinician if present.
SIGNATURE
SIGNATURE – Clinician: _________________________________________
*
*
Date Prescription Ordered: ___________________
For Division of Public Health Use Only
Patient Reporter DI.
_______________________________________ Send to:
WI Case No. _______________________Date ___________________
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