HISPANIC NAME NAME NON-HISPANIC WEDSS # WEDSS # DOB DOB RACE: RACE WEIGHT WEIGHT kg lb
3HP Monitoring
Medication (select correct dose and frequency; write in for other doses): INH mg 300 mg 900 mg Daily Twice weekly Weekly Rifampin mg 600 mg Daily Twice weekly Rifapentine mg 900 mg Weekly Pyridoxine mg 25 mg 50 mg Daily Twice weekly Weekly Other mg Frequency:
Medications already taken: Please complete the pages of current medications and update it as you see the patient.
TB infection indicated by: Quantiferon positive date test drawn: Exact measurement: T-Spot positive date test drawn: Tuberculin skin test date test done: mm induration:
Liver enzymes: Please check liver enzymes before treatment, monthly if baselines are abnormal OR patient has risk factors for hepatic disease, and at least one week after the final dose if results have been abnormal during treatment.
Date AST ALT
Other lab values of interest: Lab Value Date drawn
Pre-existing problems: (please describe) Liver disease/abnormal liver enzymes
Diabetes
Renal disease
Other: Other: Other:
077df03a24f01f74941005e94e602c1d.doc HISPANIC NAME NAME NON HISPANIC WEDSS # WEDSS # DOB DOB RACE: RACE WEIGHT WEIGHT kg lb
Risk Factors Qualifying for 12 week treatment: (mark as many as applicable to patient) Conversion after exposure to TB disease (please name case, date of patient’s conversion)
New/former refugee Date of arrival (at least month and year)
At high risk for moving from infection to disease
Previous failure to complete TB infection treatment (please list when) AND at risk of moving from infection to disease
Unlikely to be able to complete treatment with self-administration AND at risk of moving from infection to disease
Directly-Observed Therapy (DOT) to be done or overseen by: PHN name Telephone number Email address
Notes:
077df03a24f01f74941005e94e602c1d.doc HISPANIC NAME NAME NON HISPANIC WEDSS # WEDSS # DOB DOB RACE: RACE WEIGHT WEIGHT kg lb
Event Monitoring: Please ask patient about EACH possible event at each visit; document how long any event had been present in the notes below.
Baseline/ Event Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Visit 1 Date Loss of appetite Nausea/ vomiting Diarrhea Fatigue Weakness Jaundice Abdominal pain Back pain Rash or hives Itching Dizziness Headache Easy bruisability Numbness/tingling Fever Visual disturbances/eye pain Urine color Joint pain/swelling Hospitalization/new dx Other: NO adverse reaction LFTs drawn? HCW visit? Rx stop?
Further details on any check marks above: (remember to date!)
077df03a24f01f74941005e94e602c1d.doc HISPANIC NAME NAME NON HISPANIC WEDSS # WEDSS # DOB DOB RACE: RACE WEIGHT WEIGHT kg lb
Event Monitoring: Please ask patient about EACH possible event at each visit; document how long any event had been present in the notes below.
Event Visit 7 Visit 8 Visit 9 Visit 10 Visit 11 Visit 12 Date Loss of appetite Nausea/ vomiting Diarrhea Fatigue Weakness Jaundice Abdominal pain Back pain Rash or hives Itching Dizziness Headache Easy bruisability Numbness/tingling Fever Visual disturbances/eye pain Urine color Joint pain/swelling Hospitalization/new dx Other: NO adverse reaction LFTs drawn? HCW visit? Rx stop?
Further details on any check marks above: (remember to date!)
077df03a24f01f74941005e94e602c1d.doc HISPANIC NAME NAME NON HISPANIC WEDSS # WEDSS # DOB DOB RACE: RACE WEIGHT WEIGHT kg lb
Medication Monitoring: Please ask patient about EACH medication at each visit; document changes in the notes below.
Visit/Date Medication/ Visit 1/ dose/ Pre-Med Visit 2 Visit 3 Visit 4 Visit 5 Visit 6 Baseline frequency
Further details on any check marks above: (remember to date!)
077df03a24f01f74941005e94e602c1d.doc HISPANIC NAME NAME NON HISPANIC WEDSS # WEDSS # DOB DOB RACE: RACE WEIGHT WEIGHT kg lb
Medication Monitoring: Please ask patient about EACH medication at each visit; document changes in the notes below.
Visit/Date Medication/ dose/ Visit 7 Visit 8 Visit 9 Visit 10 Visit 11 Visit 12 frequency
Further details on any check marks above: (remember to date!)
077df03a24f01f74941005e94e602c1d.doc HISPANIC NAME NAME NON HISPANIC WEDSS # WEDSS # DOB DOB RACE: RACE WEIGHT WEIGHT kg lb
Adverse Event Episode
Onset of # doses Date symptoms Symptom Duration Hospitalized taken Rechallenge Outcome <2 hrs <1 day hrs Yes Yes Continue Rx 2 - 48 hrs >1 day - days No No INH intolerant >48 hrs RPT intolerant <2 hrs <1 day hrs Yes Yes Continue Rx 2 - 48 hrs >1 day - days No No INH intolerant >48 hrs RPT intolerant
Outcomes: Treatment Completion
Completed treatment as ordered
Treatment suspended for [length of time] , then restarted and
completed within weeks/months.
Treatment stopped after weeks/months.
Stopped by physician due to side effects
Stopped by patient due to
Patient lost to follow-up
Patient moved to after weeks of treatment
Outcomes: Side Effects
No side effects noted
Treatment suspended for [length of time] due to side effects
Treatment stopped after side effects
Hospitalization required due to side effects
Additional laboratory studies required due to side effects
Side effects reported to FDA Medwatch http://www.fda.gov/medwatch
Side effects reported to CDC [email protected]
PHN: Upload document into NCM filing cabinet when treatment complete/stopped.
077df03a24f01f74941005e94e602c1d.doc