Tuberculosis Chemoprophylaxis Record

• Legal Form Number: BP-A0636
• Date: 2010-06
• Year: 2010
• Section: Federal Bureau of Prisons

TUBERCULOSIS CHEMOPROPHYLAXIS RECORD U.S. DEPARTMENT OF JUSTICE

FEDERAL BUREAU OF PRISONS

BP-A636

JUN 10

Register No.

Inmate's Name (Last, First, Middle Initial)

Date of Birth

Age

Sex: Male ; Female Race: White ; Black ; Asian ; Hispanic ; Native American

MEDICAL HISTORY

PPD: Current Test: Date mm; Previous test : Date mm; Unknown

HIV status: Positive ; Negative ; Not Tested Date Tested BCG: Yes ; No

Chest x-ray: Negative ; Abnormal ; Fibrotic Lesion (old TB) ; Other

Previous INH: Yes ; No DOPT: Yes ; No Adverse rx: Yes ; No

INDICATION(S) FOR PREVENTIVE RX

Close contact ; Recent convertor ; Age <35 ; Clinical condition

SCREENING HISTORY AND EXAM

Jaundice/hepatitis hx Yes ; No Dark Urine Yes ; No Wt Loss Yes

; No Cough/TB Symtoms Yes ; No

Liver disease Yes ; No Pregnancy Yes ; No Other symptoms/conditions

Examination: T P R BP Weight lbs kgs

TREATMENT HISTORY

INITIATION

Start date Drug tx mgms. Freq Duration doses

Prescribing Clinician's Name Facility

DISCONTINUATION

Preventive treatment interrupted or discontinued prior to prescribed duration- -list indication(s):

Active Case ; Deceased ; Released ; Inmate decision ; Adverse Rx ; Medical Advise ; Noncompliance

Other (indicate)

Dose taken Discontinuation Date

Evaluating clinician's Name Facility

COMPLETION

Doses Taken

Preventive treatment completion date Facility

Comments:

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