Screening Questionnaire

Patient Name

First NameLast Name

Date of Birth

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)?

Has a family member or contact had a positive TB skin test or blood test?

If Yes, when Did they take medicine? Yes No

Has your child traveled to a high-risk country for more than 4 weeks?

If Yes, when Did they take medicine? Yes No

Form Disclosure

By submitting this form, you agree that [Practice Name] may use the information you provide to respond to your request and, where applicable, to contact you about your child's care. We do not sell your information. View our full Privacy Policy at https://www.rtcpeds.com/privacy-policy.