TB Medical History Abstraction Form - School of Nursing

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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___/___/___
Page 1: TB Medical History Abstraction Form
Page 5 and 6: Relationship_______________________
Page 7 and 8: Name (Last, First MI) DOB (age) Sex
Page 9: 12) Any record in the past 2 years

TB Medical History Abstraction Form - School of Nursing

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