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