Annual Health Assessment TB Screen

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EMPLOYEE ANNUAL HEALTH QUESTIONNAIRE and TB assessment
Employee First Name*
Employee Last Name*
Last Four Digit of SSN*
Date of Birth*

MonthDayYear
Todays Date*

MonthDayYear
Part A CHECK Since the employee's last health screening, does the employee state that they have:
1. Had any significant illnesses or hospitalizations?*

NoYes, (If yes, please provide details)
2. Had Surgery in the past year?*

NoYes, (If yes, please provide details)
3. Had any injuries?*

NoYes, (If yes, please provide details)
4. Had any changes in pre-existing health problems?*

NoYes, (If yes, please provide details)
5. Developed any new health problems?*

NoYes, (If yes, please provide details)
6. Seen a physician for anything besides a routine physical or minor illness?*

NoYes, (If yes, please provide details)
7. Started on any new medications?*

NoYes, (If yes, please provide details)
8. Currently taking any prescription medications or over the counter medications?*

NoYes, (If yes, please provide details)
9. Had any complaints of shortness of breath, cough or chest pain?*

NoYes, (If yes, please provide details)
10. Had any complaints of fever or night sweats?*

NoYes, (If yes, please provide details)
11. Know of, or believe there is any health reason why they cannot or should not provide direct patient care?*

NoYes, (If yes, please provide details)
12. Had any unresolved illnesses or medical conditions?*

NoYes, (If yes, please provide details)
13. Do they have a problem with habituation or addiction to alcohol, depressants, stimulants, narcotics or other substances that may alter their behavior?*

NoYes, (If yes, please provide details)

TB assessment

Timeframe for all questions is since the employee’s last TB assessment or test.
Part B Does the employee state that they notice any of the following:
1. Unexplained fevers?*

NoYes, (If yes, please provide details)
2. Night sweats?*

NoYes, (If yes, please provide details)
3. Unintentional Weight Loss?*

NoYes, (If yes, please provide details)
4. Cough for 3 or more weeks?*

NoYes, (If yes, please provide details)
5. Loss of appetite?*

NoYes, (If yes, please provide details)
6. Hoarseness?*

NoYes, (If yes, please provide details)
7. Bloody Sputum?*

NoYes, (If yes, please provide details)
8. Chest Pain?*

NoYes, (If yes, please provide details)
9. Fatigue?*

NoYes, (If yes, please provide details)
10. Have you completed INH Therapy? INH Therapy is used to treat active Tuberculosis?*

NoYes, ( If yes, please provide details including when completed)
11. History of temporary or permanent residence (for >1 month) in a country with a high TB rate*

NoYes, (If yes, please provide details of where and when travel occurred)
12. Current or planned immunosuppression, including human immunodeficiency virus infection, receipt of an organ transplant, treatment with an TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids(equivalent of prednisone >15mg/day for >1 month), or other immunosuppressive medication like chemotherapy?*

NoYes, (If yes, please provide details)
13. Close contact with someone who has had TB disease?*

NoYes, (If yes, please provide details)
Is any question was yes?
Should be Empty: