"Tuberculosis Treatment and Follow-Up Care Report Form" - Connecticut

Tuberculosis Treatment and Follow-Up Care Report Form is a legal document that was released by the Connecticut State Department of Public Health - a government authority operating within Connecticut.

Form Details:

  • Released on December 20, 2016;
  • The latest edition currently provided by the Connecticut State Department of Public Health;
  • Ready to use and print;
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Download "Tuberculosis Treatment and Follow-Up Care Report Form" - Connecticut

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Fax or mail to:
Tuberculosis Treatment and Follow-up Care
Connecticut Department of Public Health
Report Form
Tuberculosis Control Program
410 Capitol Avenue, MS #11TUB
Complete for ALL TB Disease and
P.O. Box 340308
Latent TB Infection
Hartford, CT 06134-0308
Phone: 860-509-7722 Fax: 860-509-7743
Patient Name – Last, First, Middle
Date of Birth
Date of This Evaluation
________|________|__________
________|_______|___________
MM
DD
YYYY
MM
DD
YYYY
Address – Street, City, State, Zip
Best Phone Number
Date of Next Evaluation
________|_______|___________
MM
DD
YYYY
Patient’s Insurance Status – (if changed/new)
This Patient is Being Treated For (please check one)
 Active TB Disease
 Latent TB Infection
 Uninsured  Medicare  Medicaid
 Private
 Other (specify): __________________________
CURRENT TREATMENT
Start Date
Treatment Status
 Continuing
________|________|___________
 Completed
Date Completed
MM
DD
YYYY
________|________|___________
Check Drug(s) / Complete Dosages for Current Treatment
Total Months of Treatment: _______
MM
DD
YYYY
 Isoniazid
 Rifapentine _____________(mg)
 Treatment Stopped (Complete
__________________(mg)
Date Treatment Stopped
Date Stopped at right and check
________|________|___________
 Rifampin
 Rifabutin
__________________(mg)
____________(mg)
reason below)
MM
DD
YYYY
Provide reason treatment was stopped.
 Pyrazinamide __________________(mg)
 Pyridoxine (B6) __________(mg)
 Refused
 Not TB
 Other: _________________(mg)
End Date: ____________________
 Adverse Treatment Event
Date
of Death
 Lost
 Ethambutol __________________(mg)
 Other: _________________(mg)
 Other:
________|________|___________
__________________________
MM
DD
YYYY
 Other: _________________(mg)
End Date: ____________________
 Died (complete date at right)
 Restarted (complete date at right)
If one or more drugs were stopped, please indicate which drug(s) and date:
 Moved (enter new address below)
If Restarted, Date
Directly Observed Therapy (DOT)
New Address:
________|________|___________
Is/Was Patient on DOT?
MM
DD
YYYY
 Yes, both DOT and self-
 Yes, totally DOT, if yes was it:
administered
 In Person DOT
 No, totally self-administered
 Electronic DOT
If yes, number of
Email address: ___________________________________________
If moved, were records sent to new provider/health department?  Yes
 No
doses to date:
NEW TESTING AND FOLLOW-UP, ATTACH COPIES OF ALL NEW RESULTS
Date Tested
 Positive
 Pending
All TB patients should have testing. If HIV testing was
 Negative
HIV
 Refused
________|________|___________
pending, or not initially offered, what are the results now?
 Indeterminate
MM
DD
YYYY
 No
Date Tested
Was patient tested for hepatitis?
If YES, was patient positive for:
 B 
 B
 C
HEPATITIS
________|________|___________
 C 
MM
DD
YYYY
 CXR
 Stable
Results:
Date Tested
Recommended TWO months
COMPARATIVE
 CT Scan
 Improving
after treatment started for TB
________|________|___________
IMAGING
 Worsening
 Other: ___________________ 
disease.
MM
DD
YYYY
Date first consistently negative sputum
If no sputum culture conversion within 60 days (select one):
culture. 
 Still positive culture
 Patient Lost
 Died
BACTERIOLOGY
 NO follow-up sputum despite induction
 Patient Refused
 Other (specify):
 NO follow-up sputum and NO induction
_______|________|________
_____________________
MM
DD
YYYY
Comments:
ADDITIONAL
INFORMATION
Current Health Care Provider: (Name and Address)
Telephone:
(
)
Fax:
PROVIDER
(
)
INFORMATION
Name of Person Completing This Report
Telephone:
Date of This Report
(
)
________|________|___________
MM
DD
YYYY
MAIL: White copy to CT Department of Public Health, Yellow copy to the Local Health Department, and Pink to the patient’s file.
Rev. 12/20/2016
Fax or mail to:
Tuberculosis Treatment and Follow-up Care
Connecticut Department of Public Health
Report Form
Tuberculosis Control Program
410 Capitol Avenue, MS #11TUB
Complete for ALL TB Disease and
P.O. Box 340308
Latent TB Infection
Hartford, CT 06134-0308
Phone: 860-509-7722 Fax: 860-509-7743
Patient Name – Last, First, Middle
Date of Birth
Date of This Evaluation
________|________|__________
________|_______|___________
MM
DD
YYYY
MM
DD
YYYY
Address – Street, City, State, Zip
Best Phone Number
Date of Next Evaluation
________|_______|___________
MM
DD
YYYY
Patient’s Insurance Status – (if changed/new)
This Patient is Being Treated For (please check one)
 Active TB Disease
 Latent TB Infection
 Uninsured  Medicare  Medicaid
 Private
 Other (specify): __________________________
CURRENT TREATMENT
Start Date
Treatment Status
 Continuing
________|________|___________
 Completed
Date Completed
MM
DD
YYYY
________|________|___________
Check Drug(s) / Complete Dosages for Current Treatment
Total Months of Treatment: _______
MM
DD
YYYY
 Isoniazid
 Rifapentine _____________(mg)
 Treatment Stopped (Complete
__________________(mg)
Date Treatment Stopped
Date Stopped at right and check
________|________|___________
 Rifampin
 Rifabutin
__________________(mg)
____________(mg)
reason below)
MM
DD
YYYY
Provide reason treatment was stopped.
 Pyrazinamide __________________(mg)
 Pyridoxine (B6) __________(mg)
 Refused
 Not TB
 Other: _________________(mg)
End Date: ____________________
 Adverse Treatment Event
Date
of Death
 Lost
 Ethambutol __________________(mg)
 Other: _________________(mg)
 Other:
________|________|___________
__________________________
MM
DD
YYYY
 Other: _________________(mg)
End Date: ____________________
 Died (complete date at right)
 Restarted (complete date at right)
If one or more drugs were stopped, please indicate which drug(s) and date:
 Moved (enter new address below)
If Restarted, Date
Directly Observed Therapy (DOT)
New Address:
________|________|___________
Is/Was Patient on DOT?
MM
DD
YYYY
 Yes, both DOT and self-
 Yes, totally DOT, if yes was it:
administered
 In Person DOT
 No, totally self-administered
 Electronic DOT
If yes, number of
Email address: ___________________________________________
If moved, were records sent to new provider/health department?  Yes
 No
doses to date:
NEW TESTING AND FOLLOW-UP, ATTACH COPIES OF ALL NEW RESULTS
Date Tested
 Positive
 Pending
All TB patients should have testing. If HIV testing was
 Negative
HIV
 Refused
________|________|___________
pending, or not initially offered, what are the results now?
 Indeterminate
MM
DD
YYYY
 No
Date Tested
Was patient tested for hepatitis?
If YES, was patient positive for:
 B 
 B
 C
HEPATITIS
________|________|___________
 C 
MM
DD
YYYY
 CXR
 Stable
Results:
Date Tested
Recommended TWO months
COMPARATIVE
 CT Scan
 Improving
after treatment started for TB
________|________|___________
IMAGING
 Worsening
 Other: ___________________ 
disease.
MM
DD
YYYY
Date first consistently negative sputum
If no sputum culture conversion within 60 days (select one):
culture. 
 Still positive culture
 Patient Lost
 Died
BACTERIOLOGY
 NO follow-up sputum despite induction
 Patient Refused
 Other (specify):
 NO follow-up sputum and NO induction
_______|________|________
_____________________
MM
DD
YYYY
Comments:
ADDITIONAL
INFORMATION
Current Health Care Provider: (Name and Address)
Telephone:
(
)
Fax:
PROVIDER
(
)
INFORMATION
Name of Person Completing This Report
Telephone:
Date of This Report
(
)
________|________|___________
MM
DD
YYYY
MAIL: White copy to CT Department of Public Health, Yellow copy to the Local Health Department, and Pink to the patient’s file.
Rev. 12/20/2016