Epidemiology and Disease Control Program
|Maryland Center for TB Control and Prevention Consultation Request Form |
| |
|Consultant: William Randall, M.D. / Paul Saleeb, M.D. Date:___/___/________ |
| |
|Requestor: ___________________ Phone: (___) _______ FAX: (____) _________ |
| |
|County: __________ Previous consult has occurred for this patient: yes no |
| |
|Subject: Last __________________ First___________________ MI___ DOB: ____/____/____ |
|Sex: ____ Race: ________ Country of Origin: □U.S. □______________ Arrival: ____/____ |
|Mo/Yr |
|Question: _________________________________________________ _____________ |
|_________________________________________________________________ |
|_______________________________________________________________________ |
|Current Symptoms □cough x ____ wks □productive cough □fever ______ □night sweats |
|□ NONE □weight loss ___ lbs in ___wks □chest pain □hemoptysis □other:___________ |
| |
|TB Risk Factors: |
|TST’s | Date Result |
|___/__/___ __mm |CXR’s ___/___/___ ___________________________________ |
| | |
|___/__/___ __mm | |
|□ NOT DONE |___/___/___ __________________________________ |
| | |
|QFT _____ Date: __/__/__ |Other ___/___/___ __________________________________ |
|□ NOT DONE | |
|Bacteriology □ NOT DONE | Iniitial _____/_____/____ Source: _______ Smear:_____ Cuture:_____ |
|Susceptibilities: _________ |_____/_____/____ Source: _______ Smear:_____ Cuture:_____ |
|______________________ |_____/_____/____ Source: _______ Smear:_____ Cuture:_____ |
|Conversion date __/__/__ |Recent:_____/_____/____ Source: _______ Smear:_____ Cuture:_____ |
|Pathology Report: |
|HIV □NOT DONE □ negative □ positive ____/____/____ CD4 ______ ____/____/____ VL ____________ |
|□ Abnormal labs (please attach) |
|TB Treatment Start Date ___/___/____ Current weight ___ ___ |
|□ NONE Current TB meds: _________________________________________________ |
| |
|□ PRIOR Treatment summary_______________________________________________ |
| |
|Other Medical Problems:________________________________________________________________ |
| |
|___________________________________________________________ Smoking Hx _________ |
| |
|Other Medications: |
| |
|Additional Information: __________________________________________________________ |
|_______________________________________________________________________ |
|□ Additional information attached □ See previous consult form |
| |
|Recommendations:__________________________________________ _____________ |
|_________________________________________________________________ |
|_________________________________________________________________ |
|_________________________________________________________________ |
|_________________________________________________________________ |
|MD SIGNATURE: DATE: |
|___/___/___ |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- maryland commissioner of financial regulation
- epidemiology and disease control program
- name of personnel
- citizenship status form university of maryland
- llrw report form 2020 prot maryland
- compressed work week schedule request form maryland
- maryland energy administration
- dhs letterhead final v4 maryland
- lt governor maryland
Related searches
- construction quality control program sample
- quality control program for construction
- quality control program sample
- edible flea and tick control for dogs
- oral tick and flea control for dogs
- construction quality control program template
- program control analyst duties
- program control analyst job description
- food and beverage control pdf
- food and beverage control system
- food and beverage control process
- program xfinity remote control to tv