Form Mo 580 1589 – Fill Out and Use This PDF

a. patient information

e. reason for testing

name (last, fIrst, mIddle InItIal)

PHone numBer

contact to tB case

employment

medically referred

symptomatic

Immigration

Insurance

educational enrollment

resident

Inmate numBer

student Id numBer

socIal securIty numBer

other

address/street

cIty

zIP code

emPloyer/resIdence

long term care facility

department of corrections

Health care facility

substance abuse center

school/day care

county Jail

county

date of BIrtH

WeIgHt

sex

male     

female

other

race

I consent to a tuberculin skin test (tst) for the above reason(s). I understand I am to have the skin test read in 48-72

White     

Black     

asian/Pacific Islander     

american Indian/alaskan native

hours by the designated reader/interpreter. If I do not return in 48-72 hours, I understand that I may need to have the

tst re-administered.

etHnIc orIgIn

client’s/guardian signature

date

Hispanic      

non-Hispanic

occuPatIon

alIen numBer

f. risk factors

Please cHeck all tHat aPPly

Contact to TB Case –

I.V. Drug User

Foreign Born Where TB is Common

Place of emPloyment

dcn numBer

High

Medium

Low

Homeless

Employee of Dept. of Corrections

Abnormal Chest X-Ray

Migrant Worker

Employee of other Correctional Facility

b. history of tuberculin test

Have you ever Had a Bcg vaccine?

Have you ever Had a tuBerculIn test?

WHen/date

Alcoholic

Diabetes Mellitus

Employee of Long Term Care Facility

no     

yes     

unknown

no     

yes     

unknown

Younger Than 4 Years of Age

Silicosis

Employee of Mental Health Facility

Underserved/Low Income

Provide Health Care Service

Resident of Dept. of Corrections

results In mm of PrevIous skIn test

tyPe of test

Post-Gastrectomy

Teaches High Risk Groups

Resident of Other Correctional Facility

Prolonged Corticosteroid Therapy

No Known Risk Factors

Resident of Long Term Care Facility

c. current tuberculin ppd mantouX test(s)/X-rays

date/tIme admInIstered

manufacturer

date/tIme admInIstered

manufacturer

10% or More Below Ideal Body Weight

Immunosuppressed

Resident of Mental Health Facility

Skin Test Converter With 2 Years

date/tIme read

lot numBer

date/tIme read

lot numBer

g. treatment/recommendations

status

latent tB InfectIon (ltBI)

medIcatIon ProvIded By

close   

open

no   

yes

Private Provider   

Health dept.

results In mm

admIn. sIgnature

results In mm

admIn. sIgnature

h. medication

Igra test done

date/tIme

results

drug/mg

no     

yes

Positive

negative

InH _____   

B-6 _____   

rifampin _____   

InH/rPt_____   

other_____

(Igra=t spot or quantiferon)

Borderline

Indeterminate

frequency

duratIon (In montHs)

start date

cHest x-ray done

date done

results

fIndIngs

daily 

Weekly 

2 or 3 times Weekly by dot

no     

yes

normal     

abnormal

reason treatment not started

d. health care provider

name/facIlIty

Patient refuses therapy     

Physician did not order     

medical contraindication

Previously treated (documentation Provided)

address

PHone numBer

comments

reported by

name/facIlIty

PHone numBer

address

rePort date

mo 580-1589 (7-12)

please complete back of form for treatment (for rePortIng dIsease use cd-1)

tBc-4

preventive treatment monitoring

continuation