Tuberculosis Contact Evaluation Form Template
TEMPLATE: Customize as needed02/2021Tuberculosis Contact Evaluation FormInitial contact date: __________?Tennessen Warning Interpreter needed: ?No ?Yes: __________________________Demographic InformationName: ______________________________________________________Sex: __________DOB: _______________? <5 y/oStreet/City/ZIP: ____________________________________________________ County: _________________________________Phone: ___________________________________________Race: _______________________________________ ?HispanicCountry of birth:?USA ?________________________________Date of arrival to USA:___________________Arrival city/county/state:_________________________________________Exposure InformationSetting: ?Household ?Leisure ?Work ?School ?__________ Priority: ?High ?Med ?Low Ring: ?1st ?2nd ?____Relationship to index: _____________________________________________ Date of last exposure: _______________ Describe: ________________________________________________________8-week post-exposure date: _______________TB HistoryPrevious TST: ?No ?Unk ?Positive ?Negative Induration: _________ mmDate: __________________ Previous IGRA: ?No ?Unk ?Positive ?Negative ?Borderline ?IndeterminateDate: __________________Previous treatment for LTBI:?No ?Unk ?Yes:Therapy type: ?INH ?RIF ?__________Year:___________Tx duration:_______ monthsCompleted treatment:?No ?Yes ?CurrentPrevious TB disease: ?No ?Unk ?Yes:State/Country:______________________Year:___________Tx duration:_______ monthsCompleted treatment:?No ?Yes ?CurrentAbove history provided by: ? Patient’s verbal report ? Documentation or verification from screening facilityContacts with history of TB disease, or a positive TST or IGRA should NOT receive a TST or IGRA for the current evaluation. When possible, obtain documentation of previous testing, disease, and treatment.Relevant Medical InformationPrimary provider: ____________________________________Primary clinic: _______________________________________Phone: _____________________________________________Fax: ________________________________________________Live virus (e.g. MMR, Varicella) or COVID-19 vaccine in last 4 weeks: ?No ?Yes: / / (If yes, see form instructions)Immunocompromised:?No ?Yes:? HIV InfectionImmunosuppressive therapy: ? TNF-alpha antagonists ? For post-stem cell or solid organ transplant? Moderate or high dose corticosteroid (equivalent to prednisone ≥15 mg for 1 month or longer)Immunocompromised contacts must have a CXR and a medical evaluation to rule out active TB disease. Window period prophylaxis is strongly recommended. These recommendations also apply to contacts < 5 years of age.Other risk factors:?No ?Yes:?Diabetes mellitus ?End Stage Renal Disease/Dialysis ?Tobacco use ?Chemotherapy?IV drug use ?Gastrectomy or Jejunal bypass ?Malnutrition ?Silicosis Contacts with other risk factors for progression to active TB disease do not need a CXR and medical evaluationby risk factor alone. Prioritize for evaluation and LTBI treatment, if applicable.Notes:Initial TB EvaluationName: _____________________________________________DOB: ______________ ? < 5 years oldTB symptom review date: ___________TB TestMark “Yes” if no other explanation? TSTDate placed: __________ Date read: __________ ?Not ReadCough (> 3 weeks)?No ?YesInduration: ________mm Result: ?Negative ?Positive Fever/chills?No ?YesWeight loss?No ?Yes? IGRADate: __________ ?Negative ?Positive ?Borderline ?Indeterminate Hemoptysis?No ?YesIGRA is preferred over TST for non US-born clients ≥ 2 years oldFatigue?No ?YesNotes:Loss of appetite?No ?YesChest pain?No ?YesNight sweats?No ?YesSymptomatic contacts must have prompt CXR and medical evaluation.These recommendations also apply to contacts with a positive TB test result during the current evaluation.≥ 8-Week Post-Exposure TB Evaluation? Relevant Medical Information rev’dTB TestTB symptom review date: ___________? TSTDate placed: __________ Date read: __________ ?Not ReadMark “Yes” if no other explanationInduration: ________mm Result: ?Negative ?Positive Cough (> 3 weeks)?No ?YesFever/chills?No ?Yes? IGRADate: __________ ?Negative ?Positive ?Borderline ?IndeterminateWeight loss?No ?YesIGRA is preferred over TST for non US-born clients ≥ 2 years oldHemoptysis?No ?YesNotes:Fatigue?No ?YesLoss of appetite?No ?YesChest pain?No ?YesNight sweats?No ?YesSymptomatic contacts must have prompt CXR and medical evaluation.These recommendations also apply to contacts with a positive TB test result during the current evaluation.Chest X-Ray & Medical Evaluation: < 5 Years Old | Immunocompromised | Symptomatic | Positive TB TestCXR date: _______________ ?Normal ?Abnormal, not consistent with active TB ?Abnormal, consistent with active TBEval. date: ______________ Active TB disease r/o? ?Yes ?No, CXR and/or eval not done ?No, provider could not rule outFinal Outcome? Fully Evaluated:?No TB infection or disease ?Previous positive TB test or disease ?New LTBI ?Active TB disease? Not Fully Evaluated:?Inadequate locating information ?Notified, no response ? Refused ?Failed appts. ?___________Window-Period Prophylaxis ?Indicated, not startedLTBI Treatment ?Indicated, not startedStart date: _______________ Stop date: _______________ Start date: _______________ Stop date: _______________?INH ?RIF ? _______________?INH + RPT ?RIF ?INH ? _______________Reason dc’d: ________________________________________Reason dc’d: ________________________________________Notes: ................
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