Tuberculosis Infection And Disease Form - Kansas Department Of Health And Environment
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2KANSAS DEPARTMENT OF HEALTH AND ENVIRONMENT
BUREAU OF DISEASE CONTROL AND PREVENTION: TUBERCULOSIS CONTROL PROGRAM
TUBERCULOSIS INFECTION AND DISEASE FORM
PLEASE TYPE OR PRINT NEATLY
:
COUNTY OF RESIDENCE
Event Information:
_____ Active
____ Suspect
____ TB Infection
EPI TRAXNumber: _______________________________________
_____ Contact to an active case
Name of Active Case: __________________________________________________
Occupation: ___________________________________________
Patient Name:_____
________
Name of Employer/School:________________________________
Last
First
Middle
Day Time Phone (
)_________________________________
Referral Source:______________________________________________________
Evening Phone (
)_________________________________
Address:
____
_______________________
Street/Route
City/Town
State
Zip Code
Parent/Guardian Name:
___________________________________________ ________
Telephone Number: (
)___________________________
Last
First
Middle
Address:
____
_______________________
Street/Route
City/Town
State
Zip Code
Race: Mark all that apply
Gender:
Ethnicity:
Date of Birth:
____ American Indian/Alaskan Native
____ Native Hawaiian/Other Pacific Islander
Male
____ Asian
____ Race not otherwise specified
Female
Not Hispanic or Latino
_______/_______/________
____ Black/African American
____ White
Hispanic or Latino
Country of Birth:
USA
_____ Other (specify)
Date of Arrival: ______/______/______
______ Refugee _____ Recent Immigration
____ Class B1
____ Class B2
____ Homeless in the past year
In the past year, does the patient
HIV Status
____ Resident of a Correctional Facility at diagnosis
have a history of:
____Negative (Date) _____________________
Inmate #___________________________________
_____ Alcohol abuse
____ Positive (Date) ______________________
____ Resident of a long-term care facility at diagnosis
_____ Non-IV drug use
____ Indeterminate
____ Test Done, Results Unknown
Name of Facility
_____ IV drug use
____ Patient Refused Test ____ Unknown
__________
____ Test Not Offered
_________________________________________
MEDICAL HISTORY (Mark all that apply)
SYMPTOMOLOGY of TB Disease (Mark all that apply)
___ Productive Cough
Date of Onset:______/______/______
____ Asthma
____ Pneumonia
____ Bronchitis
____ Weight Loss
____ Fever
____ Hypertension ____ Cancer, current disease ___ Cancer, previous episode
____ Night Sweats
____ Fatigue
____ Diabetes
____ Hepatitis
___ Cardiac Disease
____ Chest Pain
____ Shortness of Breath
____ Tobacco Use ____ Other___________________________________
____ Lymphadenopathy ____ Hemoptysis
____ Hematuria
X-Ray Date:
/
/
Normal, Negative, or NEAD
Abnormal
Month
Day
Year
If Abnormal, please attach radiological interpretation
Current Interferon Gamma Release Assay Result: Date drawn:
/
/
Date Reported:
/
/
Positive ____
Negative _____
Month
Day
Year
Month
Day
Year
Type of Test: Quantiferon _______ T-Spot ________
Indeterminate ____
Previous Interferon Gamma Release Assay Result: Date drawn:
/
/
Date Reported:
/
/
Positive ____
Negative _____
Month
Day
Year
Month
Day
Year
Type of Test: Quantiferon _______ T-Spot ________
Indeterminate ____
Current PPD Skin Test Reading: Date Planted:
/
/
Date Read:
/
/
Induration (mm): _____
Positive ____
Negative _____
Month
Day
Year
Month
Day
Year
Previous PPD Skin Test Reading: Date Planted:
/
/
Date Read:
/
/
Induration (mm): _____
Positive ____
Negative _____
Month
Day
Year
Month
Day
Year
RISK CRITERIA USED IN ESTABLISHING THE SIGNIFICANCE OF THE PPD SKIN TEST REACTION
Local Health authorities may determine that certain groups are at an increased risk for TB. Usually health care workers are considered positive at 10mm induration.
Contact KDHE, or your local health department for more information.
5 mm or more
10 mm or more
15 mm or more
____ HIV Infection
____ Recent arrivals from high prevalence countries
____ No known
____ Close Contact to a TB case
____ Injection Drug Users
risk factors
____ Fibrotic changes on CXR
____ Residents and employees of high-risk congregate settings*
consistent with old TB
____ Mycobacteriology laboratory personnel
____ Organ Transplant
____ Persons with clinical conditions that make them high-risk**
____ Other immunosuppressed patients
____ Children <4 years of age, or children and adolescents exposed to adults in high- risk
categories
*Health Occupations, or residential settings that increase the risk of TB include:
___ Health Care Worker
___ Homeless Shelter
___ Rehabilitation Center
___ Long Term Care Facility
___ Correctional Facility
___ Mycobacteriology Lab
___ Other _____________________
**Medical conditions that increase the risk of TB include:
____diabetes mellitus
____ corticosteroid therapy
____cancer of the head and neck
____ silicosis
____ immunosuppressive therapy
____chronic malabsorption.
____ end-stage renal disease
____ hematologic and reticuloendothelial diseases
____ intestinal bypass or gastrectomy ____ TNf Inhibitors
Form Updated 7/18/2013
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