TB Medical History Abstraction Form - School of Nursing

TB Medical History Abstraction Form
1) Identifiers
RVCT# ____________________________
___/___/___
SSN _____-____-_____ DOB:
ID# (specify type) ____________________________________________________
Name: (Last)________________________ (First)___________________________
Alias/Maiden: (Last)________________________
(First)___________________________
Address (at time of diagnosis):
_______________________________________________________
(Street/Apt#)
________________________________________________________
(City) (State)
(ZIP)
Home (____) ____-_____ Work (____) ____-_____ Other (____) ____-
_____
2) Demographics
Sex: M F
Race: White
Black
Asian/Pacific Islander
American Indian/Alaskan Native
If yes, tribal affiliation__________________________
reservation_____________________________
Other: ______________________
Ethnicity: Hispanic Not Hispanic
Primary language (other than English): Spanish Vietnamese Other
_____________
Country of origin: USA
Other: ___________________ with date arrived in US (m/y):
___/___
3) TB History
BCG Vaccination: Yes No Unknown
If Yes, when vaccinated? newborn school child adult unknown
TB Exposure: No known exposure unknown
Yes to whom, when, and where?…

Tuberculin Skin Test (TST) History:
Name_________________________________
Relationship____________________________
Time of Exposure___/___ to ___/___
mm/yy mm/yy
Name_________________________________
Relationship____________________________
Time of Exposure___/___ to ___/___
mm/yy mm/yy
Date: ___/___/___ Mantoux Tine Unknown
“Positive” “Negative”
RESULT: (mm induration) _______mm Unknown
Was patient anergic? Yes No Unknown
===========================================================
Date: ___/___/___ Mantoux Tine Unknown
“Positive” “Negative”
RESULT: (mm induration) _______mm unknown
Was patient anergic? Yes No Unknown
===========================================================
Date: ___/___/___ Mantoux Tine Unknown
“Positive” “Negative”
RESULT: (mm induration) _______mm unknown
Was patient anergic? Yes No Unknown
===========================================================
Date: ___/___/___ Mantoux Tine Unknown
“Positive” “Negative”
RESULT: (mm induration) _______mm unknown
Was patient anergic? Yes No Unknown
TB Preventative Therapy: Medication given:___________________________
Start: ___/___ End: ___/___ Total # months taken: __________
Previous TB Disease Yes No
Diagnosis
If yes, month-year of diagnosis: ___/___
Provider: Name__________________________________________________
City ____________________________ State ________________
Facility : Name__________________________________________________
City ____________________________ State ________________
Symptoms
Cough Fever Weight Loss Night Sweats
Other ________________________________
Month-year of symptom onset pre-diagnosis: ___/___

Site of Disease:
Pulmonary Pleural Lymphatic Meningeal
Other ________________________________
Laboratory results:
AFB positive Yes Count________ No N/A Specimen
type______________
Culture pos Yes No N/A Specimen
type______________
If culture positive, name of laboratory
__________________________________________
If culture positive, susceptibility results (indicate sensitive S, resistant R) N/A
INH___ Rifampin___ Ethambutol___ PZA___
Strep___
CXR: Normal Abnormal Not done Unknown
If abnormal Cavitary Non-Cavitary
Therapy:
Rx Start Date ___/___/___ Rx Stop Date ___/___/___
Reason Rx stopped: Completed Moved Lost Refused
Unknown Other ____________________________
Current TB:
Diagnosis:
Month-year of diagnosis: ___/___
Provider: Name__________________________________________________
City ____________________________ State ________________
Facility : Name__________________________________________________
City ____________________________ State ________________
Symptoms Date of onset pre-diagnosis
Productive cough ___/___/___
Fever ___/___/___
Chills ___/___/___
Weight Loss ___/___/___
Night Sweats ___/___/___
Hemoptysis ___/___/___
Chest pain ___/___/___
Other ______________________ ___/___/___
Major site of disease:
Pulmonary Pleural Lymphatic Meningeal
Other ________________________________
CXR at diagnosis: Date___/___/___
Normal Abnormal Not done Unknown
If abnormal Cavitary Non-Cavitary
CXR prior to diagnosis, if available Date___/___/___

Normal Abnormal Not done Unknown
If abnormal Cavitary Non-Cavitary
Laboratory results:
AFB positive Yes No N/A
If yes, date first positive specimen ___/___/___ Specimen Type
_______________
If sputum, degree of positivity (i.e. 4+, # AFB per
HFP)_________________________
Date last positive specimen ___/___/___
Culture positive Yes No N/A
If yes, date first positive specimen ___/___/___ Specimen Type
_______________
Date last positive specimen ___/___/___
If culture positive, susceptibility results (indicate sensitive S, resistant R)
Not done Unknown
Original:
INH___ Rifampin___ Ethambutol___ PZA___
Strep___
Final (if change):
INH___ Rifampin___ Ethambutol___ PZA___
Strep___
Therapy:
Rx Start Date ___/___/___ Rx Stop Date ___/___/___
Initial drug regimen: INH Rifampin PZA
Etham
Strep Rifamate Rifitur
Others _______________
Final drug regimen: INH Rifampin PZA
Etham
Strep Rifamate Rifitur
Others _______________
Current Rx status: Currently receiving Completed Moved
Lost
Refused Died Unknown
Other _________
4) Contacts:
Any documented potential sources of infection? Yes No
If yes: Name_______________________________________________________

Relationship__________________________________________________
Name_______________________________________________________
Relationship__________________________________________________
Any documented potential secondary cases? Yes No
If yes: Name_______________________________________________________
Relationship__________________________________________________
Name_______________________________________________________
Relationship__________________________________________________
5) Risk Factors for TB:
Immunosuppressive Rx______________________________________________
Diabetes End-stage renal failure
HIV: Positive Negative Indeterminate Refused
Not offered Test done, results unknown Unknown
Any record of the following in the 2 years prior to diagnosis:
Yes No Unk
Intravenous drug use
(Type/frequency_____________________________)
Non-IV drug use
(Type/frequency_____________________________)
Excess alcohol use
(Frequency_________________________________)
Anything else of value from the chart that you feel would be useful for retracing patient
during their time of infectiousness, or relating to their participation in activities that put
them at risk for transmission?
________________________________________________________________________
__________________
________________________________________________________________________
__________________

__________________
Contact Investigation Review Date of chart review ___/___/___
Name of chart reviewer___________
1) Case name:______________________________
Alias?_______________________________
Estimated period if infectiousness: Start ___/___/___ End___/___/___
Address_____________________________
City/state____________________________
2) Was a contact investigation performed? Yes No Unknown
If not, reason not performed___________________________________________
3) Who performed the contact investigation?
Name of organization________________________________________________
4) How long has case lived at above address? Is any information known about prior
places of residence (particularly reservations)?
5) Please list all the names of contacts identified during the investigation and general
results of their evaluations in the table on the following page:

Name (Last, First MI) DOB
(age)
Sex Relation City/state of
residence
HML? Evaluation Result (i.e. dates and
results of TSTs/CXRs, incomplete
eval., lost to follow up)
TST
converter?

6) Did the case report any travel in the two years prior to the start of the infectious period?
Yes No Not addressed in chart
If yes, please list details of travel (i.e. dates, destination, duration of stay)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
7) Did the case report any travel during the infectious period?
Yes No Not addressed in chart
If yes, please list details of travel (i.e. dates, destination, duration of stay)
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
8) Does the patient have any known connections to any of the following areas? (i.e. originally
from the area, visited the area in distant past, has friend from the area, etc)
Seattle area (If yes, explain:__________________________________)
Spokane area (If yes, explain:__________________________________)
Fort Peck area (If yes, explain:__________________________________)
Other Montana sites (If yes, explain:________________________________)
9) Did the case report spending time in certain places in the two years prior to the start of the
infectious period? (i.e. drinking hang-out, bar, shelter, restaurants, etc) Explain:
10) Did the case report spending time in certain places during the infectious period? (i.e.
drinking hang-out, bar, shelter, restaurants, etc) Explain:
11) Was the case working during the two years prior to diagnosis?
Yes No No information in chart
If yes,
#1 Place/Location__________________ ____ Job_____________________
Approximate dates___________________ # days/week______________
#2 Place/Location__________________ ____ Job_____________________
Approximate dates___________________ # days/week______________

12) Any record in the past 2 years of:
Rehab program Yes No No mention in chart
Facility Name_____________________________________
City____________________________ State___________
Date of admission ___/___/___
Homelessness Yes No No mention in chart
Shelter_____________________________________
City____________________________ State______
Date of admission ___/___/___
Shelter_____________________________________
City____________________________ State______
Date of admission ___/___/___
Shelter_____________________________________
City____________________________ State______
Date of admission ___/___/___
Hospitalizations Yes No No mention in chart
Hospital____________________________________
City____________________________ State______
Date of admission ___/___/___ Date of discharge ___/___/___
Hospital____________________________________
City____________________________ State______
Date of admission ___/___/___ Date of discharge ___/___/___
Hospital____________________________________
City____________________________ State______
Date of admission ___/___/___ Date of discharge ___/___/___
Hospital____________________________________
City____________________________ State______
Date of admission ___/___/___ Date of discharge ___/___/___
Nursing Home
Residence Yes No No mention in chart
Facility_____________________________________
City_____________________________ State_____
Date of Admission ___/___/___
Incarcerations Yes No No mention in chart
Facility____________________________________
City____________________________ State______
Date of admission ___/___/___ Date of discharge ___/___/___
Facility____________________________________
City____________________________ State______
Date of admission ___/___/___ Date of discharge ___/___/___