Name: DOB:
Name: DOB: | |
TST: mm induration Date Read: | |
QFT: ( Pos ( Neg ( Indeterminate Date: | |
Chest X-Ray: Date: | | ( Normal ( Abnormal (Stable)
Treatment Completed: ( Yes ( No (Contact Provider)
Name of Drug(s):
Started: | | Stopped: | | # Mos:
Provider Name:
Signature: Phone: ( )
|Name: DOB: | |
TST: mm induration Date Read: | |
QFT: ( Pos ( Neg ( Indeterminate Date: | |
Chest X-Ray: Date: | | ( Normal ( Abnormal (Stable)
Treatment Completed: ( Yes ( No (Contact Provider)
Name of Drug(s):
Started: | | Stopped: | | # Mos:
Provider Name:
Signature: Phone: ( )
|Name: DOB: | |
TST: mm induration Date Read: | |
QFT: ( Pos ( Neg ( Indeterminate Date: | |
Chest X-Ray: Date: | | ( Normal ( Abnormal (Stable)
Treatment Completed: ( Yes ( No (Contact Provider)
Name of Drug(s):
Started: | | Stopped: | | # Mos:
Provider Name:
Signature: Phone: ( )
| |
|Name: |Name: |Name: |
|DOB: | | |DOB: | | |DOB: | | |
| | | |
|TST: mm induration Date Read: ||TST: mm induration Date Read: ||TST: mm induration Date Read: ||
|| || || |
| | | |
|QFT: ( Pos ( Neg ( Indeterminate Date: | | |QFT: ( Pos ( Neg ( Indeterminate Date: | | |QFT: ( Pos ( Neg ( Indeterminate Date: | | |
| | | |
|Chest X-Ray: Date: | | ( Normal ( Abnormal (Stable) |Chest X-Ray: Date: | | ( Normal ( Abnormal (Stable) |Chest X-Ray: Date: | | ( Normal ( Abnormal (Stable) |
| | | |
|Treatment Completed: ( Yes ( No (Contact Provider) |Treatment Completed: ( Yes ( No (Contact Provider) |Treatment Completed: ( Yes ( No (Contact Provider) |
| | | |
|Name of Drug(s): |Name of Drug(s): |Name of Drug(s): |
| | | |
|Started: | | Stopped: | | |Started: | | Stopped: | | |Started: | | Stopped: | | |
|# Mos: |# Mos: |# Mos: |
| | | |
|Provider Name: |Provider Name: |Provider Name: |
| | | |
|Signature: Phone: ( )|Signature: Phone: ( )|Signature: Phone: ( )|
| | | |
| | | |
|Name: |Name: |Name: |
|DOB: | | |DOB: | | |DOB: | | |
| | | |
|TST: mm induration Date Read: ||TST: mm induration Date Read: ||TST: mm induration Date Read: ||
|| || || |
| | | |
|QFT: ( Pos ( Neg ( Indeterminate Date: | | |QFT: ( Pos ( Neg ( Indeterminate Date: | | |QFT: ( Pos ( Neg ( Indeterminate Date: | | |
| | | |
|Chest X-Ray: Date: | | ( Normal ( Abnormal (Stable) |Chest X-Ray: Date: | | ( Normal ( Abnormal (Stable) |Chest X-Ray: Date: | | ( Normal ( Abnormal (Stable) |
| | | |
|Treatment Completed: ( Yes ( No (Contact Provider) |Treatment Completed: ( Yes ( No (Contact Provider) |Treatment Completed: ( Yes ( No (Contact Provider) |
| | | |
|Name of Drug(s): |Name of Drug(s): |Name of Drug(s): |
| | | |
|Started: | | Stopped: | | |Started: | | Stopped: | | |Started: | | Stopped: | | |
|# Mos: |# Mos: |# Mos: |
| | | |
|Provider Name: |Provider Name: |Provider Name: |
| | | |
|Signature: Phone: ( )|Signature: Phone: ( )|Signature: Phone: ( )|
| | | |
| | | |
| |YOUR TB TEST AND TREATMENT RECORD |YOUR TB TEST AND TREATMENT RECORD |
|YOUR TB TEST AND TREATMENT RECORD |Keep this card in your wallet at all times |Keep this card in your wallet at all times |
|Keep this card in your wallet at all times |Show this card to the doctor, so you don’t get tested and/or treated |Show this card to the doctor, so you don’t get tested and/or treated |
|Show this card to the doctor, so you don’t get tested and/or treated |again |again |
|again |Call your doctor if you have any signs or symptoms of TB disease for |Call your doctor if you have any signs or symptoms of TB disease for |
|Call your doctor if you have any signs or symptoms of TB disease for |2 or more weeks: |2 or more weeks: |
|2 or more weeks: |- Cough |- Cough |
|- Cough |- Feeling weak and tired |- Feeling weak and tired |
|- Feeling weak and tired | | |
| |- Chest pain |- Chest pain |
|- Chest pain |- Fever and chills |- Fever and chills |
|- Fever and chills | | |
| |- Coughing up blood |- Coughing up blood |
|- Coughing up blood |- Night sweats |- Night sweats |
|- Night sweats | | |
| |- Losing weight without trying |- Losing weight without trying |
|- Losing weight without trying | | |
| | | |
| | | |
| |Have you found this card useful? Call 1-800-482-3627 |Have you found this card useful? Call 1-800-482-3627 |
|Have you found this card useful? Call 1-800-482-3627 | | |
| | | |
| | | |
| | | |
|YOUR TB TEST AND TREATMENT RECORD |YOUR TB TEST AND TREATMENT RECORD |YOUR TB TEST AND TREATMENT RECORD |
|Keep this card in your wallet at all times |Keep this card in your wallet at all times |Keep this card in your wallet at all times |
|Show this card to the doctor, so you don’t get tested and/or treated |Show this card to the doctor, so you don’t get tested and/or treated |Show this card to the doctor, so you don’t get tested and/or treated |
|again |again |again |
|Call your doctor if you have any signs or symptoms of TB disease for |Call your doctor if you have any signs or symptoms of TB disease for |Call your doctor if you have any signs or symptoms of TB disease for |
|2 or more weeks: |2 or more weeks: |2 or more weeks: |
|- Cough |- Cough |- Cough |
|- Feeling weak and tired |- Feeling weak and tired |- Feeling weak and tired |
| | | |
|- Chest pain |- Chest pain |- Chest pain |
|- Fever and chills |- Fever and chills |- Fever and chills |
| | | |
|- Coughing up blood |- Coughing up blood |- Coughing up blood |
|- Night sweats |- Night sweats |- Night sweats |
| | | |
|- Losing weight without trying |- Losing weight without trying |- Losing weight without trying |
| | | |
| | | |
| | | |
|Have you found this card useful? Call 1-800-482-3627 |Have you found this card useful? Call 1-800-482-3627 |Have you found this card useful? Call 1-800-482-3627 |
| | | |
| | | |
| | | |
|YOUR TB TEST AND TREATMENT RECORD |YOUR TB TEST AND TREATMENT RECORD |YOUR TB TEST AND TREATMENT RECORD |
|Keep this card in your wallet at all times |Keep this card in your wallet at all times |Keep this card in your wallet at all times |
|Show this card to the doctor, so you don’t get tested and/or treated |Show this card to the doctor, so you don’t get tested and/or treated |Show this card to the doctor, so you don’t get tested and/or treated |
|again |again |again |
|Call your doctor if you have any signs or symptoms of TB disease for |Call your doctor if you have any signs or symptoms of TB disease for |Call your doctor if you have any signs or symptoms of TB disease for |
|2 or more weeks: |2 or more weeks: |2 or more weeks: |
|- Cough |- Cough |- Cough |
|- Feeling weak and tired |- Feeling weak and tired |- Feeling weak and tired |
| | | |
|- Chest pain |- Chest pain |- Chest pain |
|- Fever and chills |- Fever and chills |- Fever and chills |
| | | |
|- Coughing up blood |- Coughing up blood |- Coughing up blood |
|- Night sweats |- Night sweats |- Night sweats |
| | | |
|- Losing weight without trying |- Losing weight without trying |- Losing weight without trying |
| | | |
| | | |
| | | |
|Have you found this card useful? Call 1-800-482-3627 |Have you found this card useful? Call 1-800-482-3627 |Have you found this card useful? Call 1-800-482-3627 |
| | | |
| | | |
| | | |
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