INMATE NAME
ID #
DOB
TB/LTBI Clinic Flow Sheet for Correctional Facilities
NAME OF PERSON COMPLETING THIS FORM:
TITLE:
______________
NAME OF HEALTH DEPARTMENT STAFF ASSIST:
TITLE:
______________
INMATE AKA
AKA DOB
INMATE ADDRESS
CITY/STATE/ZIP
EMERGENCY CONTACT NAME
PHONE
RECORD SEARCH INFORMATION
SENT TO
DATE
FAX #
PREVIOUS TX
YEAR
WHERE
DATE
READ DATE
DATE
CLASS
TST ADMIN
CHEST X-RAY
 Yes
 No
 Normal  Abnormal
CONFIRMED TX
TREATMENT
NO MEDICATIONS ORDERED
MEDICATIONS ORDERED
Start Date _____________________________
INH
MG
DAILY X
MONTHS
DOSES
B6
MG
DAILY X
MONTHS
DOSES
EMB
MG
DAILY X
MONTHS
DOSES
Rifampin
MG
DAILY X
MONTHS
DOSES
Rifamate
MG
DAILY X
MONTHS
DOSES
Other Medications
(Please List)
______________________________________________________________________
LABS ORDERED/SPUTUMS/EDUCATION
LABS
ORDERED
CMP
CBC
HIV
LFTs
SPUTUM
SAMPLES
EDUCATION PROVIDED
HEPATITIS SCREEN
MONTHLY 
URIC ACID
OTHER
MONTHS
#1 COLLECTED – DATE
#2 COLLECTED – DATE
#1 RESULTS
#2 RESULTS
#3 COLLECTED – DATE
#3 RESULTS ___________________
MEDICATION AUTHORIZATION SIGNED
SOUTHEASTERN NATIONAL TUBERCULOSIS CENTER (SNTC)  HTTP://SNTC.MEDICINE.UFL.EDU  888-265-7682  SNTC@MEDICINE.UFL.EDU
CLINIC VISITS
BASELINE
Month 1
Month 2
Month 3
Month 4
Month 5
Month 6
Month 7
Month 8
Month 9
ALL MEDICATIONS MUST BE BY DIRECTLY OBSERVED - SWALLOWING (DOT)
MEDICATIONS
# DOSE
INH
B6
EMB
RIF
B/P
PULSE
TEMP
URINE
SKIN
ASSESSMENT
ABDOMEN
COUGH
NIGHT SWEATS
RASH
NEUROPATHY
OTHER (describe)
VISION
COLOR
HEARING
SPUTUM
WBC
Hgb
PLATELETS
LABS
AST
ALT
URIC ACID
HIV
HEPATITIS A
HEPATITIS B
HEPATITIS C
Clinician’s Initials
DATE TREATMENT COMPLETED
TREATMENT NOT COMPLETED – REASON
DATE RELEASED FROM FACILITY?
NUMBER OF DOSES
Refuses Medication
RELEASE PLAN INITIATED
Yes
Other
DISPOSITION
COMMENTS
CONFIDENTIAL MEDICAL RECORDS - Upon release or treatment completion, send record to this health department: ________________________
SOUTHEASTERN NATIONAL TUBERCULOSIS CENTER (SNTC)  HTTP://SNTC.MEDICINE.UFL.EDU  888-265-7682  SNTC@MEDICINE.UFL.EDU
No