TB Screening Questionnaire

    TB SCREENING QUESTIONNAIRE

    Name:

    Phone:

    Date:

    Date of Birth:

    Address:

    City:

    State:

    SSN:

    Employer:

    Sex MaleFemale


    TB RISK FACTORS AND MEDICAL CONDITIONS:

    1. Have you ever had a positive skin or blood test?

    YesNo

    2. Chronic or unexplained cough?

    YesNo

    3. Persistent night sweals?

    YesNo

    4. Loss of appetite?

    YesNo

    5. Hemoptysis (spitting & coughing of blood)?

    YesNo

    6. Chronic fatigue?

    YesNo

    7. Low grade fever persisting over weeks or months?

    YesNo

    8. Have you ever been treated for a significant tuberculin skin test?

    If YES, please mention the medication, date and location

    YesNo

    9. Have you had pneumonia or bronchitis in the past year? If YES, please explain.

    YesNo

    10. Have you ever received BCG vaccine? If YES, please mention date and place

    YesNo

    11. Has there ever been anyone in your household with Suspected TB? If YES, please explain.

    YesNo

    12. Has there ever been anyone in your household with Diagnosed TB?

    YesNo

    13. Have you ever lived in a country other than the USA? If YES, please list the countries.

    YesNo

    14. Have you ever travelled to Mexico or the far east or any other places where the rate of TB is High?

    YesNo

    15. Are you receiving treatment with Prednisone, cancer chemotherapy, or x-ray therapy?

    YesNo

    Date

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