Name:
Phone:
Date:
Date of Birth:
Address:
City:
State:
SSN:
Employer:
Sex MaleFemale
1. Have you ever had a positive skin or blood test?
YesNo
2. Chronic or unexplained cough?
3. Persistent night sweals?
4. Loss of appetite?
5. Hemoptysis (spitting & coughing of blood)?
6. Chronic fatigue?
7. Low grade fever persisting over weeks or months?
8. Have you ever been treated for a significant tuberculin skin test?
If YES, please mention the medication, date and location
9. Have you had pneumonia or bronchitis in the past year? If YES, please explain.
10. Have you ever received BCG vaccine? If YES, please mention date and place
11. Has there ever been anyone in your household with Suspected TB? If YES, please explain.
12. Has there ever been anyone in your household with Diagnosed TB?
13. Have you ever lived in a country other than the USA? If YES, please list the countries.
14. Have you ever travelled to Mexico or the far east or any other places where the rate of TB is High?
15. Are you receiving treatment with Prednisone, cancer chemotherapy, or x-ray therapy?
Date
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