TB-202_Initial_Health_Risk_Assessment-History_09_2020v2.pdf

Texas Department of State Health Services Tuberculosis Initial Health Risk Assessment/History

Last Name First Name DOB Sex

Street Address City County Zip Code

Phone 1 Phone 2 SSN

Pediatric TB Patients (<15 years old) Country of birth for primary guardian(s): Primary guardian relationship:

Patient lived outside US for >2 months:

Yes No Unknown Countries:

Demographics Country of birth: Born in the US (or born abroad to a parent who was a U.S. citizen):

Yes No Date of arrival in the US:

Races: American Indian or Alaskan Native

Asian Black or African American White Native Hawaiian or Pacific Islander Other Unknown Refuse

Ethnicity: Hispanic Not Hispanic or Not Latino Unknown Refused

Middle Eastern: Yes No If yes, specify country(ies): Extended race(s):

Foreign Birth or Travel Immigration status at first entry to the US: Not applicable Immigrant visa Student visa Employment visa

Tourist visa Family/fiancé visa Refugee Asylee or parolee Other immigration status Unknown Specify other:

Notice of arrival of alien with TB class: A B1 B2 B3 Alien number:

Binational status: Contacts Laboratory/radiologic testing Counter Border Crosser or Transnational

Not Counted Border Crosser Counted by Binational Program Only/Binacional Residence or travel in country with high prevalence of TB in last 2 years:

Yes No Country:

Date of travel: Approximate length of stay/residence:

Have you traveled for 8 consecutive hours while symptomatic?

Yes No

Method of transportation: Flight Bus Train Ship/boat

Specify:

Comments:

Middle Name

State

Clinical Date of clinical assessment:

Weight: lbs kgs Height: ft in cm

Weight at least 10% less than ideal body weight:

Comments:

Estimated weight, 3 months ago: lbs kg Blood pressure: systolic diastolic O2 sats: Temperature: Heart Rate:

Yes No

FDLMP:

TB-202 Tuberculosis Initial Health Risk Assessment/History – Revised 2/2020; CCHCS updated 09/2020 1/5

Initial Assessment Date of assessment: Assessment conducted by:

Primary reason evaluated for TB: Contact investigation Immigration medical exam Health care worker

Employment/administrative testing Targeted testing TB symptoms Abnormal chest radiograph (consistent with TB) Incidental lab result Unknown home Hospital Jail/prison Location of the assessment:

Long term care facility

Clinic Patient Other, specify other:

e010068 Line

TB-202 Tuberculosis Initial Health Risk Assessment/History – Revised 2/2020; CCHCS updated 09/2020 2/5

Last First Middle DOB

Medical History Date medical history collected:

Allergies: Yes No Comments:

Arthritis/gout: Yes No Use of Remicade Humira Enbrel

Comments:

Autoimmune: Yes No Comments:

Cancer: Head Neck Other Specify other:

Comments:

Chronic malabsorption syndrome: Yes No Comments:

Chronic renal failure: Yes No Comments:

Corticosteroids (received equivalent of >15 mg/day Prednisone for >1 month): Yes No

Comments:

Diabetes mellitus: Yes No Type 1 Type 2

Comments:

Diabetes controlled: Yes No Unknown Comments:

Controlled through: Pills Insulin Unknown Comments:

GI/gastrectomy or jejunoileal bypass: Yes No Comments:

Gynecological: Yes No Comments:

Heart disease/PVD: Yes No Comments:

Hypertension/CVA: Yes No Comments:

Intellectual disability/developmental delay: Yes No Comments:

Leukemia: Yes No Comments:

Liver disease/hepatitis (risk factors HepB/C: IDU, HIV+ or birth in Asia, Africa or Amazon basin): Yes No

Comments:

Lymphoma: Yes No Comments:

Mental illness(es): Yes No Anxiety

Depression Schizophrenia Other Unknown Specify other:

When (select all that apply):

Currently Within past 12 months Ever

Comments:

Neurological/seizures: Yes No Comments:

Organ transplant: Yes No Comments:

Post partum: Yes No Comments:

Respiratory problems: Yes No Comments:

Silicosis/asbestosis: Yes No Comments:

Skin disease: Yes No Comments:

STD: Yes No Comments:

Surgeries/hospitalizations: Yes No Comments:

Thyroid: Yes No Comments:

Vision/hearing disorder: Yes No Comments:

Other medical history: Yes No Specify other:

Comments:

Primary care provider: Yes No Name of primary care provider: Phone:

Specialty care provider: Yes No

Pulmonologist Neurologist

Infectious disease Other

Specialty type:

Internal medicine Specify other:

Name of specialty care provider:

Phone:

HIV status: Indeterminate Not offered Positive

Negative within past year Refused

Test done-results unknown Unknown

City/County HIV#:

CD4 count, if HIV+: Date, if HIV+:

HIV counseling and referral provided: Yes No

Barriers to compliance: Yes No Comments:

Live virus immunization in last 6 weeks: Yes No Date:

FluMist (influenza) MMR (measles, mumps, rubella) MMRV (measles, mumps, Immunizations received:

rubella, varicella) Rotavirus Herpes zoster (shingles) Smallpox Varicella Yellow fever

No

N/A N/A

N/A

Pregnant/Pregnancy Patient is pregnant: Yes No Unknown If no, Patient pregnant within year previous to diagnosis:

Yes No Unknown If yes, as of (date): Outcomes(s): Live birth Miscarriage Still birth

Termination Other Specify other:

Due date: Outcome date:

Placenta evaluated: Yes No Term delivery: Yes No Unknown Pregnancy clinical notes: Baby evaluated for TB: Yes No Unknown

Evaluation result: Positive Negative Indeterminate Other Unknown

Specify other:

Outcome of evaluation: TB infection

TB infection window period TB suspect TB disease No TB disease or infection

Live birth facility:

Did anyone in the patient's household have a baby in the last 3 months? Yes No Unknown

Previous History of TB and TB Infection Recurrence or previous diagnosis of TB or TB infection: TB Disease TB Infection No Unknown History: Documented Self report Previous TB occurred in US: Yes No State/Country: State case number (if reported in Texas after 1993):

Most recent year of previous diagnosis: More than one previous episode: Yes No Unk Start date previous TB treatment:

Stop date previous TB treatment:

Previous TB drug regimen/Dosage (mg):

Previous TB treatment documented:

Yes No Unknown

Previous TB treatment considered complete:

Yes No Unknown

Start date previous TB infection treatment:

Stop date previous TB infection treatment:

Previous TB infection drug regimen/Dosage (mg):

Previous TB infection treatment documented:

Yes No Unknown

Previous TB infection treatment considered complete:

Yes No Unknown

Yes No QFT Previous positive IGRA:

T-SPOT Date:

Previous Date of chest X-Ray:

Normal Unknown

Yes No Previous positive TST:

Induration: mm Date:

Result:

Cavitary Non-cavitary

Comments:

History of TB Exposure Known exposure to active TB case: Yes No How many years: Greater than 3 years 3 years or less Date: Relationship to patient:

Comments:

Symptoms TB symptoms screening performed: Yes No Patient is symptomatic: Yes No Unknown Date of TB symptoms assessment:

Symptom Onset date Symptom Onset date Chest pain:

Yes No Not applicable Weight loss (>10%):

Yes No Not applicable Shortness of breath:

Yes No Not applicable Frequent urination, bloody urine or flank pain:

Yes No Not applicable

TB-202 Tuberculosis Initial Health Risk Assessment/History – Revised 2/2020; CCHCS updated 09/2020 3/5

Abnormal Abnormal result:

TB-202 Tuberculosis Initial Health Risk Assessment/History – Revised 2/2020; CCHCS updated 09/2020 4/5

Symptoms Fever/chills:

Yes No Not applicable Headache, decreased level of consciousness or neck stiffness:

Yes No Not applicable Night sweats:

Yes No Not applicable Swelling of joint/vertebra:

Yes No Not applicable Cough (persistent x3 weeks):

Yes No Not applicable Enlarged cervical lymph nodes:

Yes No Not applicable Productive cough:

Yes No Not applicable Swelling of lymph nodes:

Yes No Not applicable Hemoptysis:

Yes No Not applicable Eye pain or blurry vision:

Yes No Not applicable Fatigue:

Yes No Not applicable Pain swelling in other locations:

Yes No Not applicable Loss of appetite:

Yes No Not applicable Other: Yes No Not applicable Specify other:

Source of symptom information: Patient interview Relative/friend Medical record Other

Specify other:

Respiratory isolation indicated: Yes No Date placed in respiratory isolation:

Notes:

Risk and Social History Population Risks Medical Risks

Contact to infectious TB patient (2 years or less):

Yes No Unknown

Cancer: Head Lung Neck

Contact to MDR-TB case (2 years or less):

Yes No Unknown

Chronic renal failure or on hemodialysis:

Yes No Unknown

Inner-city resident: Yes No Unknown If patient has diabetes, was nutrition education provided:

Yes No

Low income: Yes No Unknown End-stage renal disease: Yes No Unknown History of homelessness (current or previous):

Yes No Unknown History of untreated or inadequately treated active TB, including fibrotic changes on X-Ray consistent with previous TB: Yes No Unknown

Current resident of homeless shelter:

Yes No Unknown

Immunosuppression (not HIV/AIDS):

Yes No Unknown

Homeless within past year:

Yes No Unknown

Incomplete TB infection therapy:

Yes No Unknown

History of incarceration (current or previous):

Yes No Unknown

Missed contact (2 years or less):

Yes No Unknown

Type of correctional facility: Federal prison Juvenile correctional facility Local jail (city or

Other correctional facility county) State prison Unknown

Specify other:

Recently infected with M. tuberculosis (within the past 2 years): Yes No Unknown Skin test conversion - increase of 10mm or more within 2 years: Yes No Unknown

Is the detainee in ICE custody? Yes No TNF-alpha antagonist therapy:

Yes No Unknown

Under custody of immigration and customs enforcement:

Yes No

Yes No Unknown Other medical risks:

Specify other:

Incarceration date at diagnosis: Testing required by employer or school program:

Yes No

No

TB-202 Tuberculosis Initial Health Risk Assessment/History – Revised 2/2020 ; CCHCS updated 09/2020 5/5

Risk and Social History Population Risks Medical Risks

Current resident of long-term care facility:

Yes No Unknown

Injecting drug use within past year:

No Injected drugs Cocaine Heroin Other illicit drug Specify other:

Patient was provided additional resources: Yes No Resident of other congregate setting at diagnosis:

Colonia Displaced citizen School dorm Unaccompanied alien child/minor (UAC) Homeless Shelter Other

Specify other:

Non-injecting drug use within past year:

No Marijuana Cocaine Heroin Crack Methamphetamines Other illicit drug

Specify other:

Patient was provided additional resources: Yes No

Employee of high risk congregate setting or institution:

Yes No Unknown

Primary occupation in the past year:

Correctional facility employee Health care worker Migrant/seasonal worker Not seeking employment Retired Unemployed Other Unknown

Specify other:

Tobacco use: Yes No Packs per day: Years of use:

Patient was provided additional resources: Yes No Alcohol use: Yes No Unknown In the last 30 days, how many days did the patient consume more than 4 drinks?

0-4 days 5 days or more Unknown Patient was provided additional resources: Yes No

Correctional facility employee type:

Inmate Volunteer

Reason not seeking employment: Child Disabled Homemaker Institutionalized Student

Medical risk factor notes:

Other Clinical Information M. bovis Status

M. bovis Contact with livestock: Yes No Unknown Consumed unpasteurized dairy:

Yes No Unknown Yes No Information shared with zoonosis:

Date zoonosis notified:

M. bovis (BCG) Yes No History of BCG:

Date(s) of BCG:

Receiving BCG as cancer therapy:

Yes No Unknown Dates:

Notes

Signature of person taking history Date Signature of interpreter (if used) Date

No