TB Screening Questionnaire
Please complete this form to assist with tuberculosis (TB) screening. All information is confidential.
Personal Information
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Medical History
Have you ever been diagnosed with tuberculosis (TB)?
*
Yes
No
Have you ever received treatment for TB?
*
Yes
No
If yes, please provide details (dates, medications, duration):
Have you ever had a positive TB skin test or blood test?
*
Yes
No
Not Sure
TB Symptoms
Select any symptoms you are experiencing:
*
Persistent cough (over 2 weeks)
Coughing up blood
Fever
Night sweats
Unexplained weight loss
Fatigue
None of the above
TB Exposure Risk
In the past 12 months have you been in close contact with someone known or suspected to have TB?
*
Yes
No
Not Sure
Have you lived, worked, or traveled in a country with high rates of TB?
*
Yes
No
If yes, please specify country and duration:
Have you worked or volunteered in healthcare, correctional facilities, homeless shelters, or similar settings?
*
Yes
No
Consent and Signature
Certification
*
I certify that the answers provided above are true and complete to the best of my knowledge. I understand this screening is required for employment in home health.
Signature
*
Upload TB Skin Test, TB Blood Test, or Chest X-Ray results
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Upload TB Skin Test, TB Blood Test, or Chest X-Ray results
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Submit
Submit
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