12. Tuberculosis (TB) Risk Assessment Questionnaire

Tuberculosis (TB) Risk Assessment Questionnaire
Name

First NameLast Name
Address
Home Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
1. Are you from or have you lived for two months or more in Africa, Asia, Central or South America, or Eastern Europe?YesNo If yes, list countries
YesNo
If yes, list countries
YesNo
YesNo
YesNo
YesNo
YesNo
7. When was your last TB test or Chest x-ray to rule out TB?
Date

MonthDayYear
Date
Where given
The information above is true and complete to the best of my knowledge, and I am aware that deliberate misrepresentation may jeopardize my health. I understand that this information is confidential and will not be released without my knowledge and written permission.
Signature of Galaxy Home Care Employee
Date

MonthDayYear
Date
All information below is to be completed by an approved screener

Findings (Check all that apply)

Previous Treatment for TB disease Possible TB suspect

No risk factors for TB infection Risk(s) for infection and/or progression to disease

Previous positive TST, no prior treatment

Actions (Check all that apply)

Issued screening letter Issued Sputum containers

Referred for CXR Administered Mantoux TB Test

Referred for medical evaluation Other:
Should be Empty: