Tuberculosis Screening Questionnaire
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Date of Last TB Test
-
Month
-
Day
Year
Date
Positive TB skin test (PPD) Date
-
Month
-
Day
Year
Date
Last Chest X-Ray Date
-
Month
-
Day
Year
Date
Have you ever been treated for TB?
*
Yes
No
Do you have any concerns that you may have TB?
*
Please indicate if you are having any of the following problems for three to four weeks or longer:
Chronic Cough (greater than 3 weeks)
*
Yes
No
Production of Sputum
*
Yes
No
Blood-Streaked Sputum
*
Yes
No
Unexplained Weight Loss
*
Yes
No
Fever
*
Yes
No
Fatigue/Tiredness
*
Yes
No
Night Sweats
*
Yes
No
Shortness of Breath
*
Yes
No
If yes: Please describe
Submit
Should be Empty: