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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: _____________________________________