"Tuberculosis Case / Suspect Follow-Up Report" - Hawaii

Tuberculosis Case / Suspect Follow-Up Report is a legal document that was released by the Hawaii Department of Health - a government authority operating within Hawaii.

Form Details:

  • Released on May 1, 2010;
  • The latest edition currently provided by the Hawaii Department of Health;
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Download "Tuberculosis Case / Suspect Follow-Up Report" - Hawaii

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MAIL OR FAX TO:
TUBERCULOSIS CASE / SUSPECT FOLLOW-UP REPORT
Hawaii Tuberculosis Control Program
ATTN: TB REGISTRY DEPARTMENT
Hawaii State Department of Health
1700 Lanakila Avenue, Honolulu, HI 96817
Tuberculosis Control Program
FAX: 808-832-5624
PHONE: 808-832-5731
Name: ________________________________________________________________________________
Date of birth: ______/______/__________
LAST
FIRST
MIDDLE INITIAL
MM
DD
YYYY
Date last report received: ______/______/__________
Date current report requested: ______/______/__________
MM
DD
YYYY
MM
DD
YYYY
1. Please record all TB bacteriology results since last report:
NUCLEIC ACID
SMEAR RESULT
SPECIMEN TYPE & SITE
DRUG SUSCEPTIBILITY RESULTS
DATE
IF POSITIVE, ENTER
CULTURE
AMPLIFICATION
(E.G., SPUTUM, BRONCH WASH,
IF CULTURE POSITIVE FOR MTB,
LAB
SMEAR COUNT
(CONFIRMED BY DNA PROBE)
COLLECTED
(E.G., MTD TEST or
TISSUE, PLEURAL FLUID, ETC.)
INDICATE DRUG RESISTANCE
(E.G., 1+, 2+, 3+, 4+)
MTB-RNA, DIRECT)
Type:
NEG
POS _____
NEG
POS
PEND
NEG
MTB COMPLEX
PEND
PAN SUSCEPTIBLE
DLS
/
/
(
): ___________
Site:
PENDING
PEND
INDET
NOT TB
RESISTANT TO: ____________
Clinical
SPECIFY ID
Type:
NEG
POS _____
NEG
POS
PEND
NEG
MTB COMPLEX
PEND
PAN SUSCEPTIBLE
DLS
/
/
(
): ___________
Site:
PENDING
PEND
INDET
NOT TB
RESISTANT TO: ____________
Clinical
SPECIFY ID
Type:
NEG
POS _____
NEG
POS
PEND
NEG
MTB COMPLEX
PEND
PAN SUSCEPTIBLE
DLS
/
/
(
): ___________
Site:
PENDING
PEND
INDET
NOT TB
RESISTANT TO: ____________
Clinical
SPECIFY ID
2. Please record the TB medication regimen:
3. Patient on Directly Observed Therapy (DOT):
No
Yes
Unknown
Drug:
Dosage:
Times/week:
Start date:
Stop date:
Isoniazid
_______mg
_____
_____/_____/__________
_____/_____/__________
4. If TB regimen was stopped, specify reason:
Rifampin
_______mg
_____
_____/_____/__________
_____/_____/__________
Completed full course of TB treatment
Pyrazinamide
_______mg
_____
_____/_____/__________
_____/_____/__________
Adverse effects of medicine
Ethambutol
_______mg
_____
_____/_____/__________
_____/_____/__________
Died before completing treatment
____________ _______mg
_____
_____/_____/__________
_____/_____/__________
Lost to follow-up
(OTHER DRUG USED)
Refused to complete treatment
____________ _______mg
_____
_____/_____/__________
_____/_____/__________
(OTHER DRUG USED)
Other reason, please specify:
TB medications not started, specify reason: ___________________________________________
5. Date of chest x-ray or other chest imaging since last report: _____/_____/__________
6. Is the patient still under your supervision for TB?
Yes
Check one:
Chest x-ray
CT scan
Other: ___________________________
No, specify reason:
Check one:
Abnormal
Normal
Not Done
Completed TB treatment
Delinquent
If abnormal: Evidence of cavity:
No
Yes
Unknown
Died
Lost to follow-up
Evidence of miliary TB:
No
Yes
Unknown
Referred to different provider:
If follow-up, check one:
Stable
Worsening
Improving
________________________ ________________
NAME
PHONE
7. Date form completed: _____/_____/__________
Other reason, please specify:
_____________________________________________________
Form completed by:
Name of physican: _______________________________ Phone: __________________
8. Additional notes / remarks:
TB Follow-up Form (Rev. 5/2010)
MAIL OR FAX TO:
TUBERCULOSIS CASE / SUSPECT FOLLOW-UP REPORT
Hawaii Tuberculosis Control Program
ATTN: TB REGISTRY DEPARTMENT
Hawaii State Department of Health
1700 Lanakila Avenue, Honolulu, HI 96817
Tuberculosis Control Program
FAX: 808-832-5624
PHONE: 808-832-5731
Name: ________________________________________________________________________________
Date of birth: ______/______/__________
LAST
FIRST
MIDDLE INITIAL
MM
DD
YYYY
Date last report received: ______/______/__________
Date current report requested: ______/______/__________
MM
DD
YYYY
MM
DD
YYYY
1. Please record all TB bacteriology results since last report:
NUCLEIC ACID
SMEAR RESULT
SPECIMEN TYPE & SITE
DRUG SUSCEPTIBILITY RESULTS
DATE
IF POSITIVE, ENTER
CULTURE
AMPLIFICATION
(E.G., SPUTUM, BRONCH WASH,
IF CULTURE POSITIVE FOR MTB,
LAB
SMEAR COUNT
(CONFIRMED BY DNA PROBE)
COLLECTED
(E.G., MTD TEST or
TISSUE, PLEURAL FLUID, ETC.)
INDICATE DRUG RESISTANCE
(E.G., 1+, 2+, 3+, 4+)
MTB-RNA, DIRECT)
Type:
NEG
POS _____
NEG
POS
PEND
NEG
MTB COMPLEX
PEND
PAN SUSCEPTIBLE
DLS
/
/
(
): ___________
Site:
PENDING
PEND
INDET
NOT TB
RESISTANT TO: ____________
Clinical
SPECIFY ID
Type:
NEG
POS _____
NEG
POS
PEND
NEG
MTB COMPLEX
PEND
PAN SUSCEPTIBLE
DLS
/
/
(
): ___________
Site:
PENDING
PEND
INDET
NOT TB
RESISTANT TO: ____________
Clinical
SPECIFY ID
Type:
NEG
POS _____
NEG
POS
PEND
NEG
MTB COMPLEX
PEND
PAN SUSCEPTIBLE
DLS
/
/
(
): ___________
Site:
PENDING
PEND
INDET
NOT TB
RESISTANT TO: ____________
Clinical
SPECIFY ID
2. Please record the TB medication regimen:
3. Patient on Directly Observed Therapy (DOT):
No
Yes
Unknown
Drug:
Dosage:
Times/week:
Start date:
Stop date:
Isoniazid
_______mg
_____
_____/_____/__________
_____/_____/__________
4. If TB regimen was stopped, specify reason:
Rifampin
_______mg
_____
_____/_____/__________
_____/_____/__________
Completed full course of TB treatment
Pyrazinamide
_______mg
_____
_____/_____/__________
_____/_____/__________
Adverse effects of medicine
Ethambutol
_______mg
_____
_____/_____/__________
_____/_____/__________
Died before completing treatment
____________ _______mg
_____
_____/_____/__________
_____/_____/__________
Lost to follow-up
(OTHER DRUG USED)
Refused to complete treatment
____________ _______mg
_____
_____/_____/__________
_____/_____/__________
(OTHER DRUG USED)
Other reason, please specify:
TB medications not started, specify reason: ___________________________________________
5. Date of chest x-ray or other chest imaging since last report: _____/_____/__________
6. Is the patient still under your supervision for TB?
Yes
Check one:
Chest x-ray
CT scan
Other: ___________________________
No, specify reason:
Check one:
Abnormal
Normal
Not Done
Completed TB treatment
Delinquent
If abnormal: Evidence of cavity:
No
Yes
Unknown
Died
Lost to follow-up
Evidence of miliary TB:
No
Yes
Unknown
Referred to different provider:
If follow-up, check one:
Stable
Worsening
Improving
________________________ ________________
NAME
PHONE
7. Date form completed: _____/_____/__________
Other reason, please specify:
_____________________________________________________
Form completed by:
Name of physican: _______________________________ Phone: __________________
8. Additional notes / remarks:
TB Follow-up Form (Rev. 5/2010)