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 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 ___/___/___
Page 1 and 2: TB Medical History Abstraction Form
Page 3 and 4: Site of Disease: Pulmonary Pleura
Page 5 and 6: Relationship_______________________
Page 7: Name (Last, First MI) DOB (age) Sex

TB Medical History Abstraction Form - School of Nursing

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