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Public Health Nursing Practice Manual

8Adherence/Compliance Client accepts dx:

no

yes

Client understands TB disease process and treatment: Family understands TB disease process and treatment:

family accepts dx:

no

yes

no

yes

l imited

no limited

yes

e to ca Client has disabilities:

o no

_ _________________ yes (describe) _______________________________________________________

Client needs assistance with ADL: Agreeable to DOT: no r D O T C o n v e n i e n t t i m e / p l a c e f o _ _ yes (describe) _________________________________________________ no yes. If no, why? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

9Work Exposure:

Employed (See also H289)

UNEMPLOYED (proceed to “School Exposure”)

Occupation/ type of work: ___________________________________________________________________________ Describe the worksite/ work space environment: _________________________________________________________ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

__________________________________________________________________________________________________ Location of work: outdoor indoor more than one area Length of time spent at work/ workspace per day: __________________________________________________________ How many other people share the workspace ______________________________________________________________

Is there lunchtime or break spent in enclosed space with oth Client has been at present work x ____ year ____ months

ers

no yes Last date at work

________________________________ _______________________________

Client has more than one job: yes no _____________________________________________________________ Address of employment(s): (REFER TO H289) Previous employment if less than 6 months in present job: ___________________________________________________

Transportation to and from work:

bus

rail

private car alone

carpool

taxi

walk

bike

other

10School Exposure:

goes to school

DOES NOT GO TO SCHOOL (Proceed to “Family/Non-Family”)

Has been enrolled at present school x

_______years and

_____

months

Concurrently attends another school:

no

yes (list): __________________________________________________

Address of school(s):

(REFER TO H289)

Describe the client’s school schedule and activities/ classroom environment: ____________________________________ _________________________________________________________________________________________________ Previous school if less than 6 months at present one: _______________________________________________________ Location of classes: outdoor indoor more than one area Number of classes and length of time spent in each class ___________________________________________________ How many other people in class? ______________________________________________________________________

taxi Transportation to and from school: walk Is there lunchtime or break spent in enclosed space with others? bike other school bus _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ public bus n o yes rail _ _ _ _ _ _ _ _ _ _ _

___________________ private car alone

carpool

11Family/ Non-Family Contacts (See H289) H o w d o e s c l i e _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ n t s p e n d s p a r e t i m e ? _ _ _ _ _ _ _ _ _ _ _

________________________________________________________________________________________________ How much time does client spend with friends/other family and where? _______________________________________

________________________________________________________________________________________________ Place of worship attended/other extra curricular involvement/ frequency/ type of activities

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Comments/ Date:

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

____ ______________________

Initial

Print Name/Title

________________________ Signature/Title

____ Initial

______________________ Print Name/Title

_________________________ Signature/Title

© 2007 LAC DPH Public Health Nursing

E 16

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