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Medical Evaluation Form
Patient Name:
Physician Name:
________________________________________
__________________________________________
Address:
Address:
________________________________________
__________________________________________
________________________________________
__________________________________________
Phone Number: ___________________________ Phone Number: _____________________________
Sex: ___ Male ___Female
Fax Number: _______________________________
Date of Birth: _____________________________ Nurse: ____________________________________
Office Manager: ______________________________________________________________________
CURRENT DIAGNOSIS
___ TB Suspect
___ Pulmonary TB
INITIAL/PRESENTING SYMPT0MS
___ Fever
___ Night Sweats
___ Weight Loss
___ Decreased Appetite
___ Expectoration
___ Chest Pain
___ Non-Pulmonary TB (site): __________________
Date of onset: _______________________________
___ Chills
___ Fatigue
___ Cough
___ Hemoptysis
HISTORY OF PRIOR TREATMENT
___ Latent TB Infection ___ TB Disease
Therapy Completed:
___ Yes
Dates of Previous Treatment: __________________
___ No
MANTOUX TUBERCULIN TEST
Date Administered: ________________________ Date Read:________ mm of induration: _________
RADIOLOGIC EXAMINATION
Chest x-ray
Date: _____________________ Results: ___________________________________
CT Scan
Date: _____________________ Results: ___________________________________
BACTERIOLOGY FINDINGS
Lab Slip
Date
Sensitivity
Source
Lab
Smear
__________
__________
___________
__________
__________
__________
__________
Culture
Number
Pattern
Name
__________
__________
__________
___________
___________
__________
__________
__________
___________
___________
__________
__________
__________
___________
BASELINE BLOOD TESTS (WITHIN 30 DAYS)
AST/SGOT (U/L) ___________
ALT/SGPT _________________
Total Bilirubin ______________
Direct Bilirubin _____________
Creatinine _________________
Other ______________________
Alkaline phosphatase _________
PAST MEDICAL HISTORY
___ Diabetes
___ Cancer
___ Asthma
___ Hypertension
___ HIV Infection
___ Other
___ Pneumonia ___ Alcohol
___ Allergies
___ Illicit Drug Use Type:
BASELINE VITAL SIGNS
Blood Pressure: ___________________________ Weight: ___________________________________
Visual Acuity: ____________________________ Color Vision: _______________________________
Hearing: _________________________________
INITIAL TB MEDICATION REGIMEN
Isoniazid________mg.
Rifampin________mg.
Date started: _______________________________
Pyrazinamide________mg. Ethambutol________mg.
Other(s): ________________________________
CURRENT MEDICATIONS (OTHER THAN FOR TB)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Next scheduled appointment: ________________
Physician’s Signature: ______________________ Date: _____________________________________