TB TARGETED MEDICAL QUESTIONAIRE FORM
Your First Name
Your Last Name
Have you ever had a positive TB skin test or history of TB infection? If the answer is YES, please answer the following:
Have you ever had the BCG vaccine?
Do you have prolonged or recurrent fever?
Have you recently lost weight?
Do you have a chronic cough?
Do you cough up blood?
Do you have sweating at night?
Do you have any of the following risk factors which may substantiallyIncrease the risk of tuberculosis?
Silicosis (Lung Disease)
Weight 10% or more below ideal body weight?
Chronic Tental Disease
Prolonged high-dose corticosteroid therapy or other
Hematologic Disorder 1.e. leukemia or lymphoma
Exposure to HIV or AIDS
Should be Empty: