Annual TB Questionnaire
Special Home Care, LLC
Employee Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Please Complete the following as applicaple to you.
*
Rows
Yes
No
UK
Have you ever been diagnosed with TB or treated for tuberculosis?
Have you ever had a positive TB skin test (PPD)?
Have you ever had chest X-Ray looking for TB?
Have you ever had the BCG vaccine?
Do you have prolonged or recurrent fever, chills, fatigue, or night sweats?
Have you recently lost weight or lost appetite?
Do you have a chronic cough?
Do you cough up blood?
Do you have chest pain?
Have you travelled out of the country?
Have you received COVID-19 vaccine in the past 4 weeks?
Are you currently pregnant?
*
Yes
No
N/A
Do you have any of the following risk factors which may substantially increase the risk of tuberculosis? (Please, check all that applies)
Rows
Please Check
Silicosis (lung disease)
Gastrectomy
Intestinal Bypass
Weight 10% or more below ideal body weight?
Chronic Renal Disease
Diabetes Mellitus
Prolonged high-dose corticosteroid therapy or other immunosuppressive therapy
Hematologic Disorder i.e., leukemia or lymphoma
Exposure to HIV or AIDS
Other malignancies
Other
Employee Signature
*
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: