TB Medical History Abstraction Form - School of Nursing

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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? ________________________________________________________________________ __________________ ________________________________________________________________________ __________________
Page 1 and 2: TB Medical History Abstraction Form
Page 3: Site of Disease: Pulmonary Pleura
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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