Tuberculosis Medication Administration Form
Record essential details for tuberculosis medication administration. Please complete all fields accurately.
Patient Full Name
*
First Name
Last Name
Patient Record Number
*
Date and Time of Administration
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Medication Name
*
Please Select
Isoniazid
Rifampin
Ethambutol
Pyrazinamide
Other
Medication Dose (mg)
*
Route of Administration
*
Oral
Intravenous
Intramuscular
Other
Pre-administration Allergies/Contraindications Check
*
No known allergies or contraindications
Allergy present (specify below)
Administration Status
*
Given
Not Given
Partially Given
Observed Reaction or Notes
Administering Staff Name
*
Submit Record
Should be Empty: