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TUBERCULOSIS RISK
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TB RISK
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Who is collecting info?
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1. Patient Born in At-Risk Country?
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Yes / No
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If YES, What Country?
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2. Patient Traveled to At Risk Country?
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Yes / No
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If YES, What Country?
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3. Family / Friend Positive for TB?
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Yes / No
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4. Family / Friend Positive TST/IGRA?
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Yes / No
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5. Patient spent > 3 weeks with prisoner, homeless, drug user, HIV?
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Yes / No
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6. Patient drinks raw milk / unpasteurized cheese?
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Yes / No
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7. Household Member Born in At-Risk Country?
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Yes / No
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If YES, What Country?
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8. Household Member Traveled to At-Risk Country?
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Yes / No
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If YES, What Country?
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Answered YES to any above?
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YES, then Order QuantiFERON GOLD
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Patient tested for TB in the past?
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Yes / No
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Date of Testing
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Patient tested Positive TB Skin Test (TST)?
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Yes / No
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Date
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Purified Protein Derivative (PPD)
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PPD Administered? Yes / No
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Date Administered
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Date Read
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Result of PPD
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If Positive, refer for Chest X-Ray
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Order Chest X-Ray
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MED / SURG HISTORY
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MED / SURG HISTORY
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Past MEDICAL Hx
• • •
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Past MEDICAL History Comments
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Past SURGICAL Hx
• • •
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Past SURGICAL History Comments
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CHILDHOOD illnesses
• • •
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Childhood Comments
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Childhood IMMUNIZATIONS
• • •
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Immunization Comments
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WELLNESS - MACRA
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MACRA
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A1c last drawn?
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A1c date
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Colonoscopy
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Colonoscopy date
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DEXA Scan
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DEXA Scan Date
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Diabetic Foot Exam
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DM Foot Exam date
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Flu
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Flu Vax date
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Lipid Panel
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Lipid Panel date
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Mammogram, Screening
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Mammo date
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Microalbumin
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Microalbumin date
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PAP
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PAP date
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Pneumovax
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Pneumovax date
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Spirometry
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Spirometry date
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STD Screen
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STD date
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Zostavax
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Zostavax date
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CHRONIC ILLNESS
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Open CHRONIC ILLNESS
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Cancer
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Open CANCER
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ORGAN SYSTEM AFFECTED
• • •
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STAGE
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Diabetes
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Open DIABETES
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DIABETES-RELATED SYMPTOMS
• • •
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PRIOR HOSP / uncontrolled blood sugar
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FAMILY HISTORY
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FAMILY HISTORY
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Father's MH
• • •
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Comments
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Mother's MH
• • •
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Comments
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Sibling(s)' MH
• • •
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Comments
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Grandparent's MH
• • •
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Comments
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Children(s)' MH
• • •
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Comments
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SOCIAL HISTORY
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SOCIAL HISTORY
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MARITAL Status
• • •
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Living Arrangements
• • •
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Potential Pathogen Exposure
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Occupation
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Occupational setting
• • •
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Sexual Hx
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Comments
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Caffeine
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Comments
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Alcohol
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Comments
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TOBACCO
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TOBACCO FREQUENCY
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Other Substances
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Patient's diet
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PHYSICAL EXAM
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Open PHYSICAL EXAM
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DO NOT USE - Date of last PHYSICAL EXAM
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DO NOT USE - ANNUAL PHYSICAL TODAY?
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