Tuberculosis Disease Initial Request For Medication Page 2
Download a blank fillable Tuberculosis Disease Initial Request For Medication in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Tuberculosis Disease Initial Request For Medication with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4F-44000 (Rev.05/2016) Tuberculosis Disease Initial Request for Medication
Page 2 of 2
Patient Name:
Patient Reporter DI:
PATIENT INFORMATION
(*Required)
A. *Tests:
Results:
Positive
Negative
Indeterminate
Invalid
Date Drawn:
1. T-Spot blood assay:
Date Drawn:
Results:
Positive
Negative
Indeterminate
2. Quantiferon blood assay:
Numeric/spot results: Nil
IU/mL
TB Nil
IU/mL
Mitogen
IU/mL
3. Tuberculin Skin Test:
Date Applied:
Date Read:
Results (induration only)
mm
Specimen
Sample Date
Results
4.
(Sputum or BAL)
Smear
PCR
Culture
Other:
5. Sputum/other culture:
Specimen source:
Date positive culture reported
B. *Is patient symptomatic? (check all that apply)
No
Fever
Night sweats
Cough > 3 weeks
Sputum
Blood in sputum
Weight loss
Other
C. *Reason for referral for treatment: (check all that apply)
Suspect TB disease
Confirmed TB disease
Contact to a current or past case of TB: Name of case, if known
D. *Chest X-Ray or CT: (Include copy of chest x-ray and/or CT report with this request)
Results:
Normal
Abnormal
Cavitary
Date
E. *Prior treatment for tuberculosis infection or disease?
NO
YES Please explain:
F. Risk factors for adverse reactions or non-adherence?
Specify
G. *Risk factors for drug-resistance or poor response to medication? (check all that apply)
Born outside US, or parents born outside US Country of birth:
Year arrived in US:
NA
)
Liver impairment (hepatitis, alcohol use, drug use, other
Diabetes:
Insulin-dependent
Oral hypoglycemic
Poorly-controlled
Immunosuppressed? Explain:
Population risk factor (travel outside US, jail or prison in other state/country)
H. *Baseline blood tests
Date
Result
HIV
Date
Result
ALT/AST
CBC w/platelets
Date
Result
Date
Result
T. BIL
Date
Result
S. Creatinine
Date
Result
Uric Acid
Other:
Date
Result
References
Treatment of tuberculosis. MMWR Recommendations and Reports. 52:RR-11. June 20, 2003.
th
Red Book. American Academy of Pediatrics. 29
Edition. 2012.
Submit completed form to: Local Health Department
Clear / Reset Form
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical