Tuberculosis Health Assessment/History – PEDIATRIC ASSESSMENT

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Patient Name:Last FirstMiddleBirth Date Sex Race Ethnicity

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Address:StreetCityCountyStateZip Census TractPhone: Home / Work

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Date of History:Primary Care Provider Phone Number of Primary Care Provider

MEDICAL HISTORY
Illnesses
Have there been any hospitalizations?
Yes No
If yes, Date: Reason: / Have there been any major medical problems?
Yes No
If yes, Date: medical problems:
Any childhood illnesses? (ex: chickenpox, measles, etc.) Yes No
If yes, DateIllnesses: / Fracture or other injury?
Yes No
If yes, DateWhat injuries:
Immunizations
Immunization Record obtained: Yes NoImmunizations current: Yes No
DTP: #1 # 2#3#4Booster
IPV: #1 # 2#3Booster
HIB: #1 # 2#3#4
MMR: #1 # 2
HepB: #1 # 2#3
HepA: #1 # 2 / HPV: #1 # 2#3
Varicella: #1 # 2
Meningococcal: #1
Rotavirus: #1 # 2#3
Pneumococcal: #1 # 2#3#4
Influenza: YesNo
Current Medications? / Yes No / If yes, Please list medications (name, dosage, frequency):
Allergies? / Yes No / Please list allergies
Special Dietary needs? / Yes No / Please list special dietary needs and why.
Review of Symptoms(has the child had frequent problems with any of the following (please check, circle and/or explain)
Head / loss of consciousness, injury / Other:
Eyes / Vision problems, infection, pain, lazy eye / Other:
Ears / Hearing problems, infections, pain, deformity / Other:
Nose / Frequent stuffiness, easy bleeding / Other:
Mouth / Tooth decay, poor bite, cleft palate, cleft lip / Other:
Throat / Trouble with swallowing, excessive drooling, tonsillitis / Other:
Neck / Stiffness, swelling, swollen glands / Other:
Chest/Lungs / Deformity, pneumonia, cough, asthma, cystic fibrosis / Other:
Heart / Turning ablue color, working to breath, murmur, rheumatic fever, congenital abnormalities / Other:
Abdomen / Vomiting, diarrhea, constipation, lactose intolerance / Other:
Urinary/Kidney / Crying when urinating, infections, congenital abnormalities / Other:
Skin / Rash, infection / Other:
Neurological / Development problems, seizures, meningitis, paralysis, congenital abnormalities / Other:
Endocrine / Weight at least 10% less than ideal body weight; Weight gain/loss,intolerance to heat/cold; excessive thirst, hair changes (thinning, falling out) / Other:
Arms and Legs / Deformity, abnormal posture, joint swelling, joint pain, congenital abnormalities / Other:
Hematological / Anemia, abnormal bleeding / Other:
Immunological / HIV/AIDS, Leukemia, Lymphoma / Other:
Cancer Other: / Head, Neck / Other:
Other: / Breastfeeding, / Other:

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Patient Name: LastFirst MiddleBirth Date SexDate of History:

SIGNS AND SYMPTOMS AND TUBERCULOSIS HISTORY
Signs and Symptoms
Cough (persistent - lasting more than 3 weeks) or increased work of breathing / Yes No / If yes, Date of Onset:
Weight Loss / Yes No / Today’s Weight:Est. weight 3 months ago:
Fever / Low grade fever / Yes No / Today’s Temperature:
Chills / Yes No
Poor feeding / Yes No
Sweating with feedings / Yes No
Vomiting / Yes No
Diarrhea / Yes No
Night Sweats / Yes No
Hoarse cry / Yes No
Swelling of Lymph Node(s) in neck, armpits or groin / Yes No
Frequent Urination, Bloody Urine / Yes No
Swelling of Joint / Vertebra / Yes No
Less active/Sleeping more than usual/difficult to arouse / Yes No
Lethargy / Yes No
Irritability / Yes No
Less than 6-8 wet diapers per day / Yes No
Pain/Swelling in other locations / Yes No
Tuberculosis History (Exposure)
Live virus vaccine in last 6 weeks / Yes No / If yes, Please list:
History of BCG / Yes No / If yes, Please provide Date(s):
Prior PPD Skin Test / Yes No / If yes, Please provide Date(s) and results:
Prior Chest X-Ray / Yes No / If yes, Please provide Date(s) and results:
Prior Treatment for TB / Yes No / If yes, please provide:
Date: Location: Duration:
Prior Treatment for LTBI / Yes No / If yes, please provide:
Date: Location: Duration:
Family History of TB / Yes No / If yes, please provide:
Date: Relationship to patient:
Contact to a TB Case / Yes No / If yes, please provide:
Date: Where: Source Case:
Contact to MDR-TB Case / Yes No / If yes, please provide:
Date: Where: Source Case:
SOCIAL AND ENVIRONMENTAL RISK FACTORS
Who lives at home:
Does your child attend: / Daycare Preschool Elementary School or higher None of these mentioned
Who takes care of your child: / Family Member Baby Sitter Friend Other:
Foreign Birth: / Yes No / If yes, country of Birth: Date entered into the US:
Recent Travel (last 6 months) / Yes No / If yes, Date: Location:
Additional Comments:
Printed Name and Signature of person taking history / Printed Name and signature of interpreter (if used)

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