• Tuberculosis (TB) Risk Assessment Questionnaire

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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth
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  • 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

  • 2. Have you been diagnosed with a chronic condition that may impair your immune system? YesNo If yes, check all that apply
  • 3. Have you ever resided, worked or volunteered in any of the following facilities? YesNo If yes, check all that apply. Prison, Hospital, Nursing Home, Homeless shelter, other..
  • 4. Do you currently have any of the following symptoms?YesNo If yes, check all that apply. Cough > 3 weeks Productive cough Coughing up bloodUnexplained fever Night sweats Unexplained weight lossChest pain Respiratory difficulty FatigueChills Loss of appetite Weakness
  • 5. Have you ever had contact with a person known to have active tuberculosis?
  • 6. Have you ever used injection drugs?YesNo

  • 7. When was your last TB test or Chest x-ray to rule out TB?

  • Date
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  • 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.

  • Date
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  • 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:

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