Rifampin Therapy Monitoring Form
Complete this form to monitor key aspects of rifampin therapy, including adherence, side effects, and follow-up.
Patient Name or Identifier
*
Date of Therapy Review
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Rifampin Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current Rifampin Dosage (mg)
*
Current Dosing Frequency
*
Please Select
Once daily
Twice daily
Three times daily
Other
Indication for Rifampin Therapy
*
Please Select
Tuberculosis
Latent TB Infection
Staphylococcal infection
Prosthetic device infection
Other
Missed Doses or Adherence Issues
*
Please Select
No missed doses
1–2 missed doses
3 or more missed doses
Unsure
Side Effects or Symptoms Experienced
None
Nausea or vomiting
Rash
Fever
Fatigue
Other
Liver-Related Warning Symptoms
None
Jaundice (yellowing of skin or eyes)
Dark urine
Severe fatigue
Abdominal pain
Loss of appetite
Concurrent Medications or Supplements
Clinician Notes or Follow-up Plan
Submit
Should be Empty: