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Public Health Nursing Practice Manual

PHN TB CLASS 3/5 ASSESSMENT FORM

Date received in District:

Type of Referral:

____________________________

SUBJECTIVE

1Presenting symptoms:

___________________________________________________________________________

symptomatic for TB

asymptomatic for TB

INDICATE ONSET/ DATE AND DURATION/ FREQUENCY AND CHARACTERISTICS:

Cough

no

yes

_______________________________________________________________

Productive cough

no

Hemoptysis

no

Loss of appetite

no

Weight loss

no

Fever

no

Night sweats

no

Fatigue

no

Dyspnea

no

Wheezing

no

Chest pain

no

yes yes yes yes yes yes yes yes yes yes

_______________________________________________________________ _______________________________________________________________ _______________________________________________________________ ____________________________________________________ ________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________

2Medical History and Past TB History Client currently taking TB medications: All other current medications and dosages: Previous tuberculin skin test (TST):

no yes ______________________________________________________________

no

yes (dates and result:

_____________________________________ )

Previous history of TB: Previous treatment for TB:

no no

yes (year yes

______)

pulmonary

extrapulmonary

site:

_______

Specify previous TB therapy dates, drugs, and location:

INH

Rifampin

Rifamate

EMB

PZA

other yes (dates and location):

___________ ___________

______________________________ ______________________________

yes

unknown

yes

unknown

other exposure (relationship/ date): ____________

Previous Hospitalization for TB: History of TB drug reactions: Source of TB: family history:

no no no

Contact/ exposure to someone with or suspected with TB: Current illnesses/ medical conditions and diagnoses (dates) :

no

yes, name/ when:

_______________________

__

___________________________________________________

Past history of illnesses and diagnoses (dates): ___________________________________________________________________

Inhalation exposure:

no

yes (specify):

__________________________________________________________

Hospitalization and surgery (dates and places):

__________________________________________________________________

Blood transfusions

no

yes (date):

_____________________________________________________________

Injuries:

_________________________________________________________________________________________________

Liver disease:

hx resolved hepatitis_______ hx of other type of liver disease

chronic/carrier hepatitis

_________

no hx of hepatitis

not sure

___________________________________________________________

HIV screening:

test done

no

y e s ( d a t e ) : _ _ _ _ _ _ _ _

Result:

positive

negative

unknown

Head and Neck

Eye Disorder

Ear Disorder

Respiratory

Muscular/ Skeletal

Heart Disease

Diabetes

Gastro-intestinal

Liver Disease

Kidney Disease

G.U./ Gyn

CNS

REVIEW OF SYSTEMS ( Check only if problems present):

Remarks:

________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

ALLERGIES AND DRUG REACTIONS:

none

_________________________________ _________________________________

yes (list) ___________________________________________

3 D e n t a l : l a s t c h e c k u p : _ _ _ _ _ _ _ _ _ _ _ _ _ _ d e n t v i uses dentures no dental provider no dental needs d _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ a l p r o e r _ _

needs care (Type: ___________________________________________________________________)

© 2007 LAC DPH Public Health Nursing

Date/ Initial

E 14

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