TB Risk Assessment Survey
TB Document G: State of Hawaii TB Risk Assessment for Adults and Children
Hawaii State Department of Health
Tuberculosis Control Program
1. Check for TB symptoms
If there are significant TB symptoms, then further testing (including a chest x-ray) is required for TB clearance.
If significant symptoms are absent, proceed to TB Risk Factor questions.
Does this person have significant TB symptoms? Significant symptoms include cough for 3 weeks or more, plus at least one of the following: Coughing, up blood, Fever, Night sweats, Unexplained weight loss, Unusual weakness, Fatigue
Yes
No
If yes, select any/all symptoms:
Coughing up blood
Fever
Night sweats
Unexplained weight loss
Unusual weakness
Fatigue
2. Check for TB Risk Factors
If any "Yes" box below is checked, then TB testing is required for TB clearance
If all boxes below are checked "No", then TB clearance can be issued without testing
Was this person born in a country with an elevated TB rate? Includes countries other than the United States, Australia, New Zealand, or Western and North European countries.
Has this person traveled to (or lived in) a country with an elevated TB rate for four weeks or longer?
At any time has this person been in contact with someone with infectious TB disease? (Do not check "Yes" if exposed only to someone with latent TB)
Does the individual have a health problem that affects the immune system, or is medical treatment planned that may affect the immune system? (Includes HIV/AIDS, organ transplant recipient, treatment with TNF-alpha antagonist, or steroid medication for a month or longer)
For persons under age 16 only: Is someone in the child's household from a country with an elevated TB rate?
TB Risk
Provider Name
Kaylee Nuemann, FNP
Jasmine Waipa, MD
Katherine Rorer, DO
Mackenzie Daniels, PA-C
Andrew Ken Stridiron, MD
Assesment Date
-
Month
-
Day
Year
Date
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Name and Relationship of Person Providing Information (if not the above-named person)
Name of Guardian
*
First Name
Last Name
Relationship to Patient
*
Submit
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