Get the free Tuberculosis Disease Initial Request for Medication
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DEPARTMENT OF HEALTH SERVICES
Division of Public Health
F44000 (10/2018)STATE OF WISCONSIN
s. 252.10 (7), Wis. Stats.
Wisconsin Tuberculosis Program
Telephone: 6082616319-Page 1 of 2TUBERCULOSIS DISEASE
INITIAL
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How to fill out tuberculosis disease initial request
How to fill out tuberculosis disease initial request
01
To fill out a tuberculosis disease initial request, follow these steps:
02
Obtain the tuberculosis disease initial request form from a healthcare facility or download it from the official website.
03
Fill in your personal information accurately, including your full name, date of birth, gender, and contact details.
04
Provide details about your medical history, such as any previous tuberculosis diagnoses or treatment received.
05
Answer questions related to your symptoms, including coughing, chest pain, weight loss, fatigue, and night sweats.
06
Provide information about any recent travel to areas with a high prevalence of tuberculosis.
07
Include any relevant laboratory test results, such as chest X-rays or sputum samples, if available.
08
Sign and date the form to confirm the accuracy of the provided information.
09
Submit the completed tuberculosis disease initial request form to the designated healthcare authority or facility.
10
Follow any additional instructions given by the healthcare provider regarding further investigations, appointments, or treatment.
Who needs tuberculosis disease initial request?
01
Anyone who suspects they may have tuberculosis or exhibits symptoms associated with tuberculosis should fill out a tuberculosis disease initial request.
02
This form is typically required by healthcare authorities or facilities to initiate the diagnostic process and determine the appropriate course of action.
03
People who have been in close contact with individuals diagnosed with tuberculosis or have recently traveled to areas with a high prevalence of tuberculosis may also need to fill out this request.
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What is tuberculosis disease initial request?
Tuberculosis disease initial request is the first step in reporting a suspected case of tuberculosis to the appropriate health authorities.
Who is required to file tuberculosis disease initial request?
Healthcare providers, laboratories, and healthcare facilities are required to file tuberculosis disease initial request.
How to fill out tuberculosis disease initial request?
The tuberculosis disease initial request form must be completed with all relevant information about the suspected case of tuberculosis and submitted to the health department.
What is the purpose of tuberculosis disease initial request?
The purpose of tuberculosis disease initial request is to notify the health department of a suspected case of tuberculosis for further investigation and potential intervention.
What information must be reported on tuberculosis disease initial request?
The tuberculosis disease initial request must include the patient's demographic information, symptoms, test results, and any potential contacts with other individuals.
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