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TB TARGETED MEDICAL QUESTIONAIRE FORM
Your First Name
*
Your Last Name
*
Full Name
Have you ever had a positive TB skin test or history of TB infection? If the answer is YES, please answer the following:
*
Yes
No
Have you ever had the BCG vaccine?
*
Yes
No
Do you have prolonged or recurrent fever?
*
Yes
No
Have you recently lost weight?
*
Yes
No
Do you have a chronic cough?
*
Yes
No
Do you cough up blood?
*
Yes
No
Do you have sweating at night?
*
Yes
No
Do you have any of the following risk factors which may substantially Increase the risk of tuberculosis?
*
Rows
Yes
No
Silicosis (Lung Disease)
Gastrectomy
Intestinal Bypass
Weight 10% or more below ideal body weight?
Chronic Renal Disease
Diabetes Mellitus
Hematologic Disorder I.e. leukemia or lymphoma
Exposure to HIV or AIDS
Other malignancies
員工簽名
Employee Signature
*
Date
/
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/
Day
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Date
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