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