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Nyc Medical Records


									                                                                                                                                              To order more copies of this form call the Provider Access Line: 1-866-NYC-DOH1
                     NYC Department of Health & Mental Hygiene
                                                                                             PHA No.
Form PD-16 (9/09)
                     Universal Reporting Form
        Mail completed form to: NYC Dept. of Health & Mental Hygiene; 125 Worth Street, Room 315, CN-6; New York, NY 10013 • Or report online:
P    Patient Last Name                                                                           First Name                                               Middle Name                                 DATE OF REPORT
T    Patient AKA: Last Name                                                                      AKA: First Name                                                              M.I .
I                                                                                                                                                                                                  ____ / ____ / ____
E    Date of Birth                      Age                   Country of Birth                                                                            Soc.Sec.No.
T      ____ / ____ / ________
     If patient is a child, Guardian Last Name                                                   Guardian First Name                                                          M.I.                Homeless
I                                                                                                                                                                                               Borough:     Manhattan
N    Patient Home Address                                                                                                          Apt. No.                      Zip Code                                    Bronx
F         Unknown                                                                                                                                                                                            Brooklyn
O    Home Telephone Number                                                                 Medical Record Number                                                                                             Queens
R         Unknown              ( _______ ) ________ – _____________
M                                                                                                                                                                                                            Staten Island
     Other Telephone Number                                                                Medicaid Number
A                                                                                                                                                                                                   NYC, borough unknown
          Unknown              ( _______ ) ________ – _____________                                Unknown
T    Sex                             Race (Check all that apply)                                                              Ethnicity          Hispanic               Please report non-NYC       Not NYC (Specify City/State)
I          Male           Transexual       Asian         White      American Indian/Alaska Native        Unknown              (Check one)        Non-Hispanic
O                                                                                                                                                                  residents to the appropriate ________________, _____
           Female         Unknown          Black         Other race Native Hawaiian/Pacific Islander                                             Unknown                      health jurisdiction   Unknown
Admitted to hospital?         Admission Date                                                     Is patient alive?          If no, date of death         Unknown        Is patient pregnant?      If yes, due date
                                                 ____ / ____ / ________           Unknown
    Yes        No                                                                                       Yes        No                                                          Yes      No                       Unknown
                              Discharge Date                                                            Unknown                                                                Unknown
    Unknown                                       ____ / ____ / ________           Unknown                                    _____ / _____ / ________                                            ____ / ____ / ______
DATE OF DIAGNOSIS                                         Risk Groups for Disease Exposure and/or Transmission           Unknown
                        ____ / ____ / _______              Patient works in:    Childcare       Food service    Health care     Nursing home     Other _________________________________________
DATE OF ILLNESS ONSET                                      Attends/resides in:     Nursing home     Day Care/Group baby-sit   Homeless shelter Correctional facility School     Hospital     Other _____________
      Unknown       ____ / ____ / _______                  Foreign travel: Countries ____________________________________________________                              Date returned to U.S. __ __ / __ __ / __ __
                                                      Name of Person Reporting Disease                                                                             Phone
    REPORTER INFORMATION                                                                                                                                           Number       ( _______ ) ________ – _____________
Facility of Person Reporting Disease                                                                                                                               PFI Code

Street Address                                                                                                                                 City                                   State         Zip Code

Name of Hospital/Healthcare Facility                                                                                    PFI Code                                   Phone
                                                                                                                                                                      Unknown ( _______ ) ________ – _____________
Street Address                                                                                                                                 City                              State        Zip Code

Name of Testing Laboratory                                                                                              PFI Code                                   Phone
     Unknown                                                                                                                  Unknown                                 Unknown ( _______ ) ________ – _____________
Street Address                                                                                                                                 City                              State        Zip Code
     Unknown                                                                                                                                          Unknown                        Unknown      Unknown
Name of Physician                                                                                                                                                   Phone
     Unknown                                                                                                                                                          Unknown ( _______ ) ________ – _____________
Street Address                                                                                                                                 City                              State        Zip Code
     Unknown                                                                                                                                          Unknown                        Unknown      Unknown

Call DOHMH if there is an outbreak or suspected outbreak of any disease or condition, of known or unknown etiology occurring in three or more persons or any unusual manifestation
                      of a disease in an individual. Call Provider Access Line 1-866-NYC-DOH1; after hours, call Poison Control Center 1-212-Poisons (764-7667)

 Comments (Additional space on Page 4)

                                                                                                                                                                                                                             Page 1
Patient Last Name                                                                                              First Name                                                  Medical Record Number

                                                                                                    DISEASE WITH SPECIAL INSTRUCTIONS

     Amebiasis (Entamoeba histolytica only                              Ehrlichiosis, Human monocytic ehrlichiosis                     Herpes, Neonatal: see STD section, page 3                            Salmonellosis ** Serogroup: _______
     or cases in which E. histolytica cannot be                        If human granulocytic anaplasmosis report as anaplasmosis.                                                                           If due to Salmonella typhi or paratyphi,
     distinguished from Entamoeba dispar.) **                           Encephalitis                                                   HIV/AIDS. For assistance in reporting a case of                      select Typhoid/Paratyphoid Fever
     Anaplasmosis                                                       Jul.1–Oct. 31 consider and test for West Nile virus.              HIV/AIDS, to receive the required New York State                  SARS (Severe Acute Respiratory Syndrome) *
     Formerly human granulocytic ehrlichiosis                           If due to another reportable disease (e.g. Lyme, West Nile,       Provider Report Forms (PRF), or to obtain more                    Shigellosis **
                                                                        arbovirus), report under the other disease.                       information, call (212) 442-3388.                                 Smallpox *
     Animal Bites (please fill out animal bite information below)
        Exposure to rabies *                                            Escherichia coli O157:H7 **                                       Influenza Check all that apply:                                   Staph Enterotoxin B *
     Including a bite or other exposure (e.g, scratch) to any           Escherichia coli (other) Shiga Toxin Producing **                     Suspected novel viral strain with pandemic potential          Staphylococcus aureus, vancomycin intermediate
     animal confirmed to have rabies, or from any rabies
                                                                                                                                          (e.g. H5) *                                                        and resistant *
     vector species (raccoon, bat, skunk, fox or coyote), or           Giardiasis **
     any mammal exhibiting signs suggestive of rabies.                                                                                        Death in a child younger than 18 years of age                 Source: ____________________
                                                                       Glanders *                                                         Kawasaki Syndrome
     Animal Species: _____________________                                                                                                                                                                  MIC (μg/ml): _________________
                                                                    Gonorrhea: see STD section, page 3
     Breed: __________________________
                                                                    Granuloma Inguinale: see STD section, page 3                          Legionellosis, Specify positive test:                             Streptococcus (Group A) Invasive only
     Color(s): _________________________                                                                                                     Culture Urine antigen
                                                                       Hantavirus *                                                                                                                         Specify Source: Blood CSF Unknown
     Date of Bite: ____ / ____ / ____                                                                                                        DFA        Serology                                              Other, Specify: ___________________
                                                                       Hemolytic Uremic Syndrome
     Area of body bitten __________________                                                                                               Leprosy (Hansen’s Disease)                                        Streptococcus (Group B) Invasive only
     Activity at time of bite ________________                         Hemophilus influenzae, invasive only
                                                                                                                                          Leptospirosis                                                     Specify Source: Blood CSF Unknown
                                                                       Specimen Source:
     Place of occurrence __________________                                                                                               Listeriosis                                                         Other, Specify: ___________________
                                                                          Blood         CSF          Unknown
     Treatment given: ___________________                                 Other_______________________                                    Lyme Disease                                                  Syphilis: see STD section, page 3
    Rabies prophylaxis      Yes No                                     Specify Serotype:                                                  Erythema migrans present?
    HRIG                    Yes No                                       Type B           Not typeable                                       Yes No Unknown                                                 Tetanus
                                                                         Not tested        Unknown                                                                                                          Toxic shock syndrome, For staph only.
    Rabies Vaccine          Yes No                                                                                                        Lymphocytic Choriomeningitis Virus
                                                                          Other_______________________                                                                                                      For strep select Streptococcus (Group A).
    Animal Owned Stray Unknown
    Animal’s owner (last name, first name):                                                                                            Lymphogranuloma Venereum: see STD section on Page 3                  Trachoma
    ______________________________                                                                                                                                                                          Transmissible Spongiform Encephalopathy
                                                                                   FOR ALL HEPATITIS REPORTS:                             Malaria ** Select at least one of the following:                  Creutzfeld-Jakob Disease and variants
    Address (Street, Apt.):
                                                                                                                                           falciparum vivax malariae                                        Testing done: ______________________
    ______________________________                                     Jaundice Yes No Unknown
                                                                                                                                           ovale undetermined                                                   (e.g. 14-3-3 on CSF, brain biopsy, autopsy, EEG/MRI)
    Boro/City, State, Zip:                                             ALT (SGPT) value: _____________ Unknown
                                                                       Lab reference range: ___________ Unknown                           Measles *                                                         Trichinosis: Caused by bacterium Trichinella
    Telephone Number:                                                                                                                     Melioidosis *                                                     spiralis. (Trichomoniasis, caused by Trichomonas
                                                                                                                                                                                                            vaginalis, need not be reported.)
    ( ______ ) ______ – _____________                                  Hepatitis A */**                                                   Meningitis, Aseptic/Viral
                                                                       Total Ab to Hepatitis A is NOT reportable                          Jul.1–Oct. 31 consider and test for West Nile virus.          Tuberculosis: see TB section on page 4
     Anthrax *
     Arboviral Infections *                                            IgM anti-HAV:        Pos Neg Unknown                               If due to another reportable disease (e.g. Lyme, West Nile,       Tularemia *
                                                                                                                                          arbovirus), report under the other disease.                       Typhoid /Paratyphoid Fever **
    Specify which virus: __________________
    If Dengue, West Nile or Yellow Fever, report as such.
                                                                       Hepatitis B
                                                                                                                                          Meningitis, other bacterial
    Attach copies of diagnostic laboratory results if available.       Report at least one positive hepatitis B test result:                                                                                Vaccinia disease (adverse events associated with
                                                                                                                                          Specify Organism: ___________________
                                                                       Total Ab to Hepatitis B is NOT reportable                                                                                            smallpox vaccination) *
     Babesiosis can be transmitted through blood products. If          IgM anti-HBc            Pos      Neg        Unknown                Meningococcal Disease, Invasive *                                 Vibrio spp. *
     patient has a history of receiving blood transfusion or           If positive, describe symptoms and risks in                        Test type/Specimen source:                                        Specify species: ____________________
     donating blood within 3 months of onset of illness, report                                                                             Blood culture                CSF Culture
     suspected/confirmed cases immediately.*
                                                                       comments box on page 1 and indicate sexual part-                                                                                     Viral Hemorrhagic Fever *
                                                                       ners in the past year (Check only one)                               Antigen test from CSF        Gram stain
     Botulism *                                                                                                                             Other________________________                                   West Nile Virus * Attach copies of diagnostic labora-
                                                                           Males only              Females only                                                                                             tory results if available
       Foodborne           Wound          Infant
                                                                           Males and Females       Unknown                                Monkeypox *
     Brucellosis *
                                                                       HBsAg:                   Pos          Neg         Unknown          Mumps                                                         Window Falls.
    Campylobacteriosis **
                                                                       HBeAg:                   Pos          Neg         Unknown                                                                           Falls from windows of buildings with three or more
 Chancroid: see STD section, page 3                                                                                                                                                                        apartments, by children aged ten years and younger,
                                                                       HBV Nucleic Acid:        Pos          Neg         Unknown          Pertussis for hospitalized cases*
 Chlamydia: see STD section, page 3                                                                                                                                                                        report on yellow Child Window Fall Notification
                                                                                                                                          Plague *
    Cholera */**                                                      Cases in pregnant women must be reported on the IMM5 or via                                                                          Report. For assistance call 1-866-NYC-DOH1
    Creutzfeld-Jakob Disease: see Transmissible                         Reporting Central. For information call 718-520-8245.          Poisoning: see Poisoning section, page 3
     Spongiform Encephalopathy                                                                                                            Polio *                                                           Yellow Fever * Attach copies of diagnostic labora-
                                                                       Hepatitis C                                                                                                                          tory results if available
     Cryptosporidiosis **                                                                                                                 Psittacosis
                                                                       Check all that apply:
     Cyclospora **                                                                                                                                                                                          Yersiniosis ** non-plague
                                                                          EIA with high s/co value: _____________                         Q Fever *
     Dengue                                                               RIBA pos. HCV Nucleic Acid (e.g.PCR) pos
    Attach copies of diagnostic laboratory results if available.                                                                          Rabies *
                                                                       Is this an acute/new infection? Yes No Unk
                                                                                                                                          Ricin *
     Drowning                                                          Hepatitis D
    Respiratory impairment from submersion/immersion in liquid.                                                                           Rickettsialpox
                                                                       Hepatitis E
    Drowning Location: __________________                                                                                                 Rocky Mountain Spotted Fever
                                                                       Hepatitis other/Unspecified
    Outcome: Death Morbidity No Morbidity                                                                                                 Rubella
                                                                       For hepatitis D, E, and other/unspecified, please describe in
                                                                                                                                           for an IgM positive case in pregnant women*
     Diphtheria *                                                      comments box on Page 1.
                                                                                                                                          Rubella, Congenital Syndome

Page 2            * Report suspected/confirmed cases immediately 1-866-NYC-DOH1, after hours 1-212-764-7667; Report all other results within 24 hours.                         ** Please complete Risk Groups section on front of form.
Patient Last Name                                                                                               First Name                                                 Medical Record Number

MODE OF EXPOSURE         TYPE                                                       QUANTITY                    REASON                                    Intentional                    SYMPTOM ASSESSMENT (Check all that apply)
  Ingestion                                                                           Milliliter (mL) _______   Unintentional                                 Suspected suicide
                             Lead For persons aged 16 and older indicate:                                                                                     Misuse                           None                                  Electrolyte abnormalities
  Ocular                                                                                 Mouthful _______          General                                                                     Nausea/vomiting/diarrhea              Cough/shortness of breath
                         Employer _______________________                                                          Environmental                              Abuse
  Dermal                                                                                 Sip _______                                                          Unknown                          Lethargic/stupor/coma                 Occular irritation
                         Employer Phone:                                                                           Therapeutic
  Inhalation                                                                                                       Misuse                                                                      Agitated                              Skin irritation
                            ( _____ ) _____ – ____________                               Tablespoon _______                                               Other                                Hypertensive                          Unknown
  Aural                                                                                                            Bite/sting
                                                                                         Tab/pill/cap _______      Food poisoning                            Contamination/                    Hypotensive                           Other
  Bite                       Arsenic      Cadmium          Carbon Monoxide*                                                                                     tampering
                                                                                                                   Occupational                                                                Tachycardia
                             Mercury       Pesticide                                     Taste/lick/drop_______                                              Malicious                                                               __________________
  Sting                                                                                                            Dietary                                                                     Brachycardia
  IV                         Other ________________________                              Teaspoon _______          Consumer product                                                            Seizure
                             Other ________________________                              Unknown                                                          Adverse reaction
                                                                                                                                                             Drug                        PROVIDER TREATMENT
SPECIMEN SOURCE                                                                     TIME OF EXPOSURE                                                         Food
                                         Laboratory Accession Number                ____ ____ : ____ ____                                                    Other                             No therapy required                   Irrigated eye
   Capillary Venous Urine
                                                                                                                                                             Unknown                           Oral fluids                           Oxygen
   Other _____________                                                                    AM      PM
                                         ____________________                                                                                                                                  Emesis                                Naxolone
Date Collected                                                                      VITAL SIGNS                                                                                                Lavage                                50% Dextrose/Thiamine
                                         Results (units) ___________                                                                                              Pupils:                      Activated charcoal                    Alkalinize urine
____ / ____ / ______                                                                Body Weight _________                      Resp: _______                                                   Cathartic                             N-acetylcysteine (Mucromyst)
                                         Purpose of test                               Pounds    Kilograms                                                          Dilated
Date Analyzed                                                                                                                  Temp: _______        F     C                                    Chelation                             Other:
                                            Initial Repeat                                                                                                          Constricted                Insect sting mgmt.                    __________________
____ / ____ / ______                        Follow-up                               BP: __ __ __/ __ __ __                     Pulse: __________

                                                                                                       SEXUALLY TRANSMITTED DISEASES
                                                               Specimen collection date ___ / ___ / ____                              Treatment for infant ___________________                                Syphilis Test Types. Check all that apply
              FOR ALL STD REPORTS
                                                               Treatment ________________________                                     Treatment date ___ / ___ / ____                 Unknown              1. Serologic tests for syphilis
As of the date of this report,                                                                                                                                                                                A. Non-treponemal Test
                                                               Treatment date ___ / ___ / _____                        Unknown           Mother’s Name: ____________________
 Were any of this patient’s sex partners notified of
    possible exposure to a sexually transmitted disease?           Gonorrhea (GC) Specify specimen source:                               Mother’s DOB: ____ / ____ / ______
      Yes, our office notified the partner(s)                                                                                                                                                                       Reactive        Non-reactive
                                                                     Endocervical  Urethral     Anorectal
      Yes, the patient was asked to notify partner(s)                Oropharyngeal    Urine                                                                                                                     Titer _________________
                                                                                                                                         Lymphogranuloma Venereum
      No         Unknown                                                                                                                                                                                       VDRL
                                                                     Other ________________________                                      Clinical Presentation (Check all that apply):
 Did you provide treatment for any of this patient’s                                                                                                                                                               Reactive        Non-reactive
                                                                                                                                           Proctitis Lymphadenopathy Skin lesion                                Titer _________________
    sex partners?                                                  Specify test type:
      Yes, I gave extra medication/prescription for                  Culture       Nucleic acid amplification                              Other _________________________                                Specimen collection date ___ / ___ / ____
      the sex partner(s)
                                                                     Nucleic acid hybridization                                                                                                               B. Treponemal Test
      If yes, for how many sex partners was medication/                                                                               Specimen collection date ___ / ___ / ____
      prescription provided? ______________                          Other: ______________________
                                                                                                                                                                                                               TP-PA/MHA-TP          Reactive Non-reactive
                                                                                                                                      Treatment __________________________
      Yes, I saw the sex partner(s) in my office               Specimen collection date ___ / ___ / ____                                                                                                       FTA                   Reactive Non-reactive
      No           Unknown                                                                                                            Treatment date ___ / ___ / _____                  Unknown
                                                               Treatment __________________________                                                                                                            Treponemal IgG       Reactive    Non-reactive
 For all sexually transmitted diseases, indicate              Treatment date ___ / ___ / _____                        Unknown                                                                            Specimen collection date ___ / ___ / ____
    sexual partners in past year (Check only one)
       Males only               Females only                                                                                             Stage:                                                           2. Cerebrospinal fluid tests
       Males and Females        Unknown                             Granuloma Inguinale Specify specimen source:                            Congenital
                                                                                                                                            Primary (chancre present) check all that apply                      CSF VDRL
                                                                     Penile         Vaginal       Endocervical
                                                                                                                                                Penile       Vaginal       Endocervical                              Reactive            Non-reactive
                                                                     Anorectal      Oropharyngeal
   Chancroid Specify specimen source:                                Other ________________________                                             Anorectal    Oropharyngeal                                      CSF FTA
      Penile           Vaginal       Endocervical              Specimen collection date ___ / ___ / ____                                          Other _____________________                                        Reactive            Non-reactive
      Anorectal        Oropharyngeal                           Treatment __________________________                                            Secondary                                                        Other Test: _____________________
                                                                                                                                                  Alopecia      Condylomata
      Other ________________________                           Treatment date ___ / ___ / _____                        Unknown                    Mucous patches      Rash                                      Result: _____________________
Specimen collection date ___ / ___ / ____                                                                                                      Early Latent
                                                                    Herpes, Neonatal                                                           (no symptoms, infection ≤ 1 year duration)                 Specimen collection date ___ / ___ / ____
Treatment __________________________                                Herpes simplex virus infection in infants aged 60 days or less.            Late Latent                                                     Elevated CSF protein
Treatment date ___ / ___ / _____             Unknown                 Clinical dx                                                               (no symptoms, infection of > 1 year duration)                          Yes           No
                                                                     Lab confirmed dx:       Culture   PCR                                     Tertiary (gumma or cardiovascular)
                                                                                                                                                                                                               Elevated CSF leukocytes
    Chlamydia (CT) Specify specimen source:                                Antigen detection Serologic Tzanck                            Neurologic symptoms present?                                                 Yes           No
     Endocervical   Urethral     Anorectal                     Herpes type: Type 1 Type 2 Not typed                                         Yes      No     Unknown                                       Specimen collection date ___ / ___ / ____
     Oropharyngeal     Urine
                                                                   Clinical Syndrome (check all that apply):                          Treatment :
      Other ________________________                                                                                                                                                                      3. Organism visualization
                                                                      Skin, eye, mucous membrane infection                            List Medication and Dosage:
   Specify test type:                                                 CNS involvement            Disseminated disease                                                                                           Darkfield
                                                                                                                                      ________________________________                                              Positive      Negative
     Culture       Nucleic acid amplification                      Herpes lesions present?
                                                                                                                                      Treatment date ___ / ___ / ___                Unknown                     Other test: ____________________
     Nucleic acid hybridization                                      Yes, anatomic site ________________
     EIA       DFA                                                   No        Unknown                                                                                                                          Result: _____________________
      Other: ______________________                            Specimen collection date ___ / ___ / ____                                                                                                  Specimen collection date ___ / ___ / ____

               * Report suspected/confirmed cases immediately 1-866-NYC-DOH1, after hours 1-212-764-7667; Report all other results within 24 hours.                           ** Please complete Risk Groups section on front of form.                       Page 3
 Patient Last Name                                                                       First Name                                       Medical Record Number

                                                           TUBERCULOSIS            Please complete Risk Groups section on front of form.
Tuberculosis Check all that apply                       AFB Smear                                        TB Screening Test                                                     QuantiFERON® TB-Gold in tube (QFT-GIT)
Primary disease site:        Other sites:                     Positive                                      Test Type:                                                          Positive      Negative
       Pulmonary                  Pulmonary                Smear Grade:       suspicious                                                                                        Indeterminate or Invalid
                                                                                                                History of Positive TST
       Lymphatic                  Lymphatic                   1+ rare         2+ few                                                                                           T-Spot.TB
       Bone/Joint                 Bone/Joint                                                                    TST, Size _____________ mm
                                                              3+ moderate     4+ numerous                                                                                        Positive      Negative
       Soft tissue/Muscles        Soft tissue/Muscles                                                             Positive     Negative
                                                                                                                                                                                 Borderline (equivocal)
       Peritoneal                 Peritoneal                      Negative    Pending                       Date Implanted                                                       Indeterminate or Invalid
       Meningeal                  Meningeal                       Not Done    Unknown
                                                                                                            ____ / ____ / ______                                         Date blood drawn
       Genitourinary              Genitourinary         M. tb Culture
       Gastronintestinal          Gastronintestinal            Positive       Negative                                                                                   ____ / ____ / ______
       Other:                     Other:                                                                        QuantiFERON® TB-Gold (QFT-G)
                                                               Pending        Contaminated                       Positive      Negative
   ____________              _____________                                                                                                                                     Other: ________________________
                                                               Not Done       Unknown                            Indeterminate or Invalid
Laboratory Results:                                                                                                                                                            Not done             Unknown
                                                        Nucleic Acid Amplification (NAA)
   Specimen Number ___________________                     Test Type:
       Unknown                                                  MTD Amplicor Not Done Unknown
                                                              Other: _____________________
Specimen Source:
                                                           Test Result:                                  Treatment
                                                              Positive Negative Pending                      On Anti-TB Medications       Yes         No      Unknown
      Tracheal aspirate
                                                              Not Done           Unknown                     Please complete for each medication:                       Dose                 Start Date
      Bronchial fluid/Broncho-alveolar lavage
      Lymph node                                        Pathology consistent with TB                               Isoniazid (INH)                    .                         .           ____ / ____ / ______
      Lung tissue                                            Positive       Negative                              Rifampin (RIF)                      .                         .           ____ / ____ / ______
      Pleural fluid                                          Not Done       Unknown                               Pyrazinamide (PZA)                                            .           ____ / ____ / ______
      Pleura                                               Pathology findings: ___________________                Ethambutol (EMB)                        .                     .           ____ / ____ / ______
      Blood                                                _______________________________                        Other 1                             .                         .           ____ / ____ / ______
      Urine                                                _______________________________
      Other: ________________________                                                                             Other 2                             .                         .           ____ / ____ / ______
                                                        Chest X-Ray ___ / ___ / _____                             Other 3                             .                         .           ____ / ____ / ______
Collection date ___ / ___ / _____          Unknown             Normal       Abnormal                        Isolation:                          Yes                      No                    Unknown
Testing Laboratory:_ ___________________                          Miliary     Non-Cavitary
        Unknown                                                   Cavitary     Consistent with TB        Other Medical Problems/Other Pertinent Information:
                                                                               Not consistent with TB
                                                        CT Scan       / MRI   ___ / ___ / _____
                                                                  Normal      Abnormal
                                                                  Miliary     Non-Cavitary
                                                                  Cavitary      Consistent with TB
                                                                                Not consistent with TB

 Comments (Continued from Page 1)

    Mail completed form to: NYC Dept. of Health & Mental Hygiene; 125 Worth Street, Room 315, CN-6; New York, NY 10013 • Or report online:
Page 4

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