TB Screening Form

Tuberculosis (TB) Screening Form

Must be completed by a parent/guardian if under the age of 18.
Name of Person getting TB test

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth

MonthDayYear
Date
Age
Address

Street Address

Street Address Line 2

CityState

Zip Code
County of Residence
Gender
Ethnicity
Race
Preferred Language
Email for confirmation notification of form
example@example.com
Reason for Test
This test will need to be read in 48-72 hours. Failure to have it read in that time frame by a Nurse, will result in needing another test.

Please answer the following questions:

Rows	Yes	No	If yes, explain
1. Have you ever had a positive Tuberculin skin test?
2. Have you had known exposure to TB?
3. Have you ever been diagnosed with OR treated for TB Disease? When?
4. Have you ever had an abnormal CXR (chest X-ray) suggestive of TB?
5. Are you a resident, employee, or volunteer in a high-risk congregate setting (correctional facility, nursing home, homeless shelter, hospitals, other healthcare facilities)?
6. Do you have a cough lasting 3 weeks or longer, chest pain, weakness, fatigue, weight loss, chills, fevers, and/or night sweats?
7. Are you coughing up blood or phlegm?
8. Have you had an MMR or Varicella Vaccination in the last 4 weeks?
9. Have you traveled or lived outside the U.S. in the past 2 years? (where?)

Person Signing Consent
Name of Parent/Guardian/Responsible Party

First NameLast Name
Parent Guardian Date of Birth

MonthDayYear
Date
I hereby grant full permission to Pike County Health Department, Home Health & Hospice to use photographs, videotapes, or any other record of this event including name, likeness and voice for any legitimate purpose.
How did you hear about us?
Signature
Date

MonthDayYear
Date
Should be Empty:

Tuberculosis (TB) Screening Form