Patient Tuberculosis Risk Assessment Page 3
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4Client Name _______________________________________________ DOB _______________
TB TESTING AND TREATMENT RECORD
TESTING INFORMATION
First Skin Test
Second Skin Test
Lot/Exp ______________
Date read ___________
Lot/Exp ______________
Date read _____________
Site __________________
Time read __________
Site _________________
Time read ____________
Date placed ___________
Read by ____________
Date placed ___________
Read by ______________
Time placed ___________
Induration _______mm
Time placed __________
Induration _________mm
Positive Negative
Positive Negative
Placed by _____________
Placed by ____________
IGRA Test T-Spot Quantiferon Date drawn __________________ Result Date __________________ Result _____________
Chest X-ray
Date ________________________ Results __________________________________________________________
HIV Test Negative Positive Unknown Refused (testing not done)
Sputum Culture Date _______________________ Results ___________________________________________________________
Date _______________________ Results ___________________________________________________________
Liver Function Testing Date __________________ Comments ______________________________________________________
Date __________________ Comments ______________________________________________________
Date __________________ Comments ______________________________________________________
Other testing/comments ________________________________________________________________________________________
____________________________________________________________________________________________________________
TREATMENT/MEDICATIONS
TB medication assistance may be available through the TB program. Please submit this completed risk assessment, the CXR report,
and copy of the prescription to the WDH TB program at (307) 777-5279. Patient is insured or uninsured.
Isoniazid ___________________________
Prescribing provider _________________________________
Rifapentine _________________________
Date therapy began __________________________________
Rifampin ___________________________
Date therapy completed _______________________________
Ethambutol _________________________
Date therapy discontinued _____________________________
Rifabutin ___________________________
Reason Death Adverse reaction Moved Lost to follow-up
Pyrazinamide _______________________
Diagnosed w/ active disease Non-compliant
After client completes or discontinues therapy, please complete the above section and provide proof of completion to the
TB program.
Comments
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Nurse/Clinician (signature & credentials) ________________________________________ Date ___________________
WDH TB Program • December 2016
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