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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?
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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