TB Symptom Questionnaire and Screening

Tuberculosis Symptom Questionnaire and Screening
Employee ID*
Last 4 digits of your social security number*
Phone Number*
Please enter a valid phone number.
Documentation of previous positive Tuberculin skin test reaction has been provided to the office ?*
Tuberculin skin tests are waived because of positive results. Chest X-ray obtained or results verified:*
SYMPTOM QUESTIONAIRE: Have you experienced any of the following symptoms recently?
Chronic cough (more than three weeks in duration).*
Coughing up blood or sputum every day for one week or more.*
Chronic feeling of fatigue, listlessness (more than two weeks in duration)*
Fever or chills (more than one week in duration).*
Night sweats.*
Unexplained weight loss (8 pounds or more).*
Note: HIV infection and certain medical conditions may cause a TB skin test to be negative even when TB infection is present.
Health care personnel should be considered to be an increased risk for TB if they answer “yes” to any of the following statements.
Temporary or permanent residence (for > or = 1 month) in a country with a high TB rate (i.e. any country other than Australia, Canada, New Zealand, the United States, and those in western or northern Europe)*
Current or planned immunosuppression, including human immunodeficiency virus infection, receipt of an organ transplant, treatment with a *TNF-Alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids(equivalent of prednisone > or = 15mg/day for > or = 1 month), or other immunosuppressive medication [*TNF=tumornecrosis factor]*
Close contact with someone who has had infectious TB disease since the last TB test*
Today's Date*

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Tuberculosis Symptom Questionnaire and Screening

SYMPTOM QUESTIONAIRE: Have you experienced any of the following symptoms recently?

Health care personnel should be considered to be an increased risk for TB if they answer “yes” to any of the following statements.