Latent Tuberculosis Infection (Positive Skin Test) Reporting Form

Health Care Provider Information

* Physician

City Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln

* Phone xxx-xxx-xxxx

Patient Information

* First name

* Last name

* Address

City Select City...Fort ErieGrimsbyLincolnNiagara FallsNiagara-on-the-LakePelhamPort ColborneSt. CatharinesThoroldWainfleetWellandWest Lincoln

Postal code

* Phone xxx-xxx-xxxx

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Born in Canada? Yes No

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Date of arrival unknown

Country of birth Select Country...

Does the patient identify as Indigenous? Yes No

First Nations Inuit Métis Prefer to self-describe Unknown

Specify

Reason for Testing

* What is the reason for testing for tuberculosis

• Contact of a case
• Targeted screening (dialysis)
• Routine screen (school, employment, volunteer, etc.)
• Other

Interferon Gamma Release Assay Testing

Testing ordered? Yes No

Bacillus Calmette-Guérin Status

Received Bacillus Calmette-Guérin vaccine? Yes No Unknown

Symptoms

• Asymptomatic
• Cough
• Fever
• Night sweats
• Weight loss
• Other

Risk Factors

• Heavy alcohol consumption (more than or equal to three drinks per day)
• Abnormal chest X-ray (fibronodular disease / granuloma)
• Leukemia or lymphoma
• Close contact of infectious tuberculosis case
• Diabetes
• Organ transplants
• Cigarette smoker (one pack a day)
• Cancer of the head and neck
• Silicosis
• Specialized treatment for rheumatoid arthritis or Crohn’s disease
• Chronic renal failure requiring hemodialysis
• Underweight (under 90 per cent ideal body weight)
• HIV / AIDS
• None
• Other

Follow-up

* Chest X-ray ordered Yes  No

Date Month JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day 12345678910111213141516171819202122232425262728293031 Year 2023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900189918981897189618951894189318921891189018891888188718861885188418831882188118801879187818771876187518741873

Fax copy of the patient chest x-ray report to Public Health: 905-682-6470

* Chemoprophylaxis recommended Yes  No
Fax copy of prescription to Public Health for dispensing of publicly funded medication: 905-682-6470

* Patient declines chemoprophylaxis Yes  No

* Referred to respirologist Yes  No

To whom

* Health teaching completed (patient informed of signs and symptoms)? Yes  No

Personal Information and Privacy

Any personal information or personal health information submitted in writing will be collected, used and disclosed by members of Regional Council and Regional staff in accordance with the Municipal Freedom of Information and Protection of Privacy Act or the Personal Health Information Protection Act, where applicable.

Freedom of Information

Any information you share will be used only for the intended purpose for which it was provided. If you have any questions, email foi@niagararegion.ca or call 905-980-6000 ext. 3779.