Depression Yes No Renal dysfunction Yes No ☐ Unknown Unknown Suicide attempt or ideation Yes No Vision change/loss Yes No ☐ Unknown Unknown Cardiac abnormalities Yes No Liver toxicity Yes No ☐ Unknown Unknown Hearing loss Yes No Myalgia Yes No ☐ Unknown Unknown Tinnitus Yes No Arthralgia Yes No Unknown Unknown Vestibular dysfunction Yes No Unknown Other: ___________________________ Peripheral neuropathy Yes No Unknown Other: ____________________________ At END OF TREATMENT were there any of the following side effects related to MDR-TB treatment present? Depression Yes No Renal dysfunction Yes No ☐ Unknown Unknown Suicide attempt or ideation Yes No Vision change/loss Yes No ☐ Unknown Unknown Cardiac abnormalities Yes No Liver toxicity Yes No ☐ Unknown Unknown Hearing loss Yes No Myalgia Yes No ☐ Unknown Unknown Tinnitus Yes No Arthralgia Yes No Unknown Unknown Vestibular dysfunction Yes No Unknown Other: ___________________________ Peripheral neuropathy Yes No Unknown Other: ____________________________
Depression Yes No ☐ Unknown Suicide attempt or ideation Yes No ☐ Unknown Cardiac abnormalities Yes No ☐ Unknown Hearing loss Yes No ☐ Unknown Tinnitus Yes No Unknown Vestibular dysfunction Yes No Unknown Peripheral neuropathy Yes No Unknown Renal dysfunction Yes No Unknown Vision change/loss Yes No Unknown Liver toxicity Yes No Unknown Myalgia Yes No Unknown Arthralgia Yes No Unknown Other: ___________________________ Other: ____________________________ At END OF TREATMENT were there any of the following side effects related to MDR-TB treatment present? Depression Yes No ☐ Unknown Suicide attempt or ideation Yes No ☐ Unknown Cardiac abnormalities Yes No ☐ Unknown Hearing loss Yes No ☐ Unknown Tinnitus Yes No Unknown Vestibular dysfunction Yes No Unknown Peripheral neuropathy Yes No Unknown Renal dysfunction Yes No Unknown Vision change/loss Yes No Unknown Liver toxicity Yes No Unknown Myalgia Yes No Unknown Arthralgia Yes No Unknown Other: ___________________________ Other: ____________________________
TB_V3.0_MDR_20180321.docx