Screening Questionnaire
Tuberculosis
Patient Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Was your child born in a high-risk country (countries other than the US, Canada, Australia, New Zealand or Western Europe)?
YES
NO
Has a family member or contact had a positive TB skin test or blood test?
YES
NO
If Yes, when
Did they take medicine?
Yes
No
Has your child traveled to a high-risk country for more than 4 weeks?
YES
NO
If Yes, when
Did they take medicine?
Yes
No
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