36C25518R0177-00001001.pdf

TB SCREENING QUESTIONNAIRE

Last name First name Middle name Date of birth

Address City State Zip

Home phone Cell or work phone Today’s date

CIRCLE ANY OF THE BELOW SYMPTOMS YOU HAVE TODAY

Cough Coughing up blood Fever Weight loss Tiredness Night sweats

PLEASE ANSWER THESE QUESTIONS

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Why do you need a TB test today?

Have you ever had a positive TB skin test or TB blood test? Yes No Don’t Know

Have you had a severe reaction to a TB skin test? Yes No Don’t Know

Have you ever taken medication for tuberculosis? Yes No Don’t Know

What country were you born in?

What countries have you lived in?

Have you had the BCG vaccine? Yes No Don’t Know

Have you been in contact with someone who has TB disease? Yes No Don’t Know

Have you ever used injection drugs? Yes No Don’t Know

Do you have HIV/AIDS? Yes No Don’t Know

Do you have any diseases that could affect your immune sys-tem such as cancer, leukemia or other?

Yes No Don’t Know

Do you have diabetes? Yes No Don’t Know

Do you have severe kidney disease? Yes No Don’t Know

Are you underweight or do you have a disease which affects how you absorb food and nutrients?

Yes No Don’t Know

Have you had an intestinal bypass or gastrectomy? Yes No Don’t Know

Do you take any prescription medications? List them below: Yes No Don’t Know

Name: ____________________________ _______________________________ Last First

CONSENT TO TESTING

I have received information about the TB skin test. I had a chance to ask questions which were answered to my satisfaction. I agree to return in 48-72 hours to have the test read. I understand the risks and benefits of the TB skin test and request the test be given to me. I understand that if I am symptomatic for TB or if the TB skin test is positive, results may be communicated to the physician with whom I will fol-low-up if medical care is needed.

Signature Date

DO NOT COMPLETE, FOR NURSE

**Interpreting the TST

> 5 mm is positive:

HIV infected

Recent contacts

> 10 mm is positive :

Born in or former resident of country with high TB incidence

Injection drug user

Mycobacterial lab workers

People who live/work in high risk congregate settings (health care workers, long term care, correctional facilities)

Children younger than 4 years

Infants, children and adolescents exposed to adults in high risk categories

> 15 mm is positive if there are no known TB risk factors

TST #1 TST #2

Administration

Name of person giving test

Date and time administered

Location (circle) L forearm R forearm L forearm R forearm

Tuberculin manufacturer

Tuberculin exp. date and lot #

Administrator signature

Results (48-72 hours)

Date and time read:

Number of mm of induration:

(across forearm)

______ mm ______ mm

Interpretation of reading (circle) Positive Negative Positive

Negative

Reader’s signature

People with fibrotic changes on CXR

Patients with organ transplant and others on immunosuppressant drugs (including prolonged course of oral or intravenous corticosteroids or TNF alpha inhibitors)

People with:

Diabetes, severe kidney disease, silicosis, cancer of head or neck, hematologic or reticuloendothelial disease such as Hodgkin’s disease or leukemia, intestinal bypass or gastrectomy, chronic malabsorption syndromes, low body weight