Get Whatcom County Health Department Tb Referral Form - Em Whatcomcounty

Filling out the Whatcom County Health Department TB Referral Form is an important step in managing tuberculosis health concerns. This guide will provide you with detailed, step-by-step instructions to ensure that you complete the form accurately and efficiently.

Follow the steps to complete the form successfully.

1. Press the ‘Get Form’ button to access the form and open it in your document management tool.
2. Begin by filling out the personal information section. Provide the patient's last name, first name, middle initial, date of birth, and sex. Ensure all information is accurate.
3. Enter the patient’s occupation, contact phone number, and mailing address, along with the parent or guardian's name if applicable. If consent has been signed by a parent or guardian, check the box provided.
4. In the social data section, indicate if the patient needs an interpreter and list the languages spoken at home. Provide the date of entry to the U.S. and the country of birth.
5. Next, detail the reason for screening by marking all applicable boxes in the epidemiological data section. This may include categories such as being a resident, employee, or other factors.
6. Complete the medical history section by checking the appropriate boxes for any allergies, medical conditions, or significant past medical problems. Include current medications.
7. In the substance use section, provide information regarding any history of latent or active TB, as well as any substance use history.
8. Complete the symptoms section by indicating if the patient is experiencing any of the listed symptoms. Provide additional details if necessary.
9. Fill out the referring agency section by providing the name of the agency, contact information, and if applicable, the primary care provider details.
10. Review the patient education and barriers sections to check if the client can read in English or their native language, and if pamphlets have been provided.
11. In the testing section, document the results of any TB tests administered, including TST and QFT results, along with any imaging results such as chest X-rays.
12. Finally, confirm that the release of information signature is completed, print your name, and provide your signature and title as the person completing the form.
13. Once you have filled in all the sections, you may save your changes, download, print, or share the completed form as needed.

Take the first step towards managing tuberculosis by filling out the Whatcom County Health Department TB Referral Form online today!