Loading
Form preview picture

Get TB Screening Questionnaire

TB SCREENING QUESTIONNAIRE // First name Last name Middle name Date of birth Address Home phone City Cell or work phone State Zip Today s date CIRCLE ANY OF THE BELOW SYMPTOMS YOU HAVE TODAY Cough Coughing up blood Fever Weight loss Tiredness Night sweats PLEASE ANSWER THESE QUESTIONS Why do you need a TB test today Have you ever had a positive TB skin test or TB blood test Yes No Don t Know Have you had a severe reaction to a TB skin test Have you ever taken medication for tuberculosis Have you had the BCG vaccine Have you been in contact with someone who has TB disease Have you ever used injection drugs Do you have HIV/AIDS Do you have any diseases that could affect your immune system such as cancer leukemia or other Do you have diabetes Do you have severe kidney disease Are you underweight or do you have a disease which affects how you absorb food and nutrients Have you had an intestinal bypass or gastrectomy Do you take any prescription medications List them below What country were you born in If you were not born in the U.S. when did you come here continue on next page Name Last First CONSENT TO TESTING I have received information about the TB skin test. I had a chance to ask questions which were answered to my satisfaction* I agree to return in 48-72 hours to have the test read* I understand the risks and benefits of the TB skin test and request that the test be given to me. I understand that if I am symptomatic for TB or if the TB skin test is positive results may be communicated to the physician with whom I will follow-up if medical care is needed* Signature Date DO NOT COMPLETE FOR NURSE TST 1 TST 2 Administration Name of person giving test Date and time administered Location circle L forearm Tuberculin manufacturer Tuberculin exp* date and lot Results 48-72 hours Number of mm of induration across forearm Interpretation of reading circle mm Positive Negative Reader s signature Interpreting the TST 5 mm is positive for HIV infected Recent contacts People with fibrotic changes on CXR Patients with organ transplant and others on immunosuppressant drugs including prolonged course of oral or intravenous corticosteroids or TNF alpha inhibitors Recent immigrants 5 yrs from high TB burden countries Injection drug users Mycobacterial lab workers People who live/work in high risk congregate settings health care workers long term care correctional facilities Children younger than 4 years Infants children and adolescents exposed to adults in high risk categories People with Diabetes severe kidney disease silicosis cancer of head or neck hematologic or reticuloendothelial disease such as Hodgkin s disease or leukemia intestinal bypass or gastrectomy chronic malabsorption syndromes low body weight. I had a chance to ask questions which were answered to my satisfaction* I agree to return in 48-72 hours to have the test read* I understand the risks and benefits of the TB skin test and request that the test be given to me. I understand that if I am symptomatic for TB or if the TB skin test is positive results may be communicated to the physician with whom I will follow-up if medical care is needed* Signature Date DO NOT COMPLETE FOR NURSE TST 1 TST 2 Administration Name of person giving test Date and time administered Location circle L forearm Tuberculin manufacturer Tuberculin exp* date and lot Results 48-72 hours Number of mm of induration across forearm Interpretation of reading circle mm Positive Negative Reader s signature Interpreting the TST 5 mm is positive for HIV infected Recent contacts People with fibrotic changes on CXR Patients with organ transplant and others on immunosuppressant drugs including prolonged course of oral or intravenous corticosteroids or TNF alpha inhibitors Recent immigrants 5 yrs from high TB burden countries Injection drug users Mycobacterial lab workers People who live/work in high risk congregate settings health care workers long term care correctional facilities Children younger than 4 years Infants children and adolescents exposed to adults in high risk categories People with Diabetes severe kidney disease silicosis cancer of head or neck hematologic or reticuloendothelial disease such as Hodgkin s disease or leukemia intestinal bypass or gastrectomy chronic malabsorption syndromes low body weight. .

How It Works

tb screening questionnaire rating
4.9Satisfied
42 votes

How to fill out and sign printable tb questionnaire online?

Get your online template and fill it in using progressive features. Enjoy smart fillable fields and interactivity. Follow the simple instructions below:

Feel all the advantages of completing and submitting legal forms online. Using our platform submitting TB Screening Questionnaire will take a few minutes. We make that possible through giving you access to our full-fledged editor capable of altering/fixing a document?s initial text, adding special fields, and e-signing.

Fill out TB Screening Questionnaire in just several moments by following the recommendations listed below:

  1. Find the document template you need from our collection of legal form samples.
  2. Click on the Get form key to open the document and start editing.
  3. Fill in the required boxes (they will be marked in yellow).
  4. The Signature Wizard will allow you to add your e-signature as soon as you have finished imputing information.
  5. Add the relevant date.
  6. Check the whole form to be certain you have completed all the information and no changes are required.
  7. Hit Done and download the resulting template to your gadget.

Send the new TB Screening Questionnaire in an electronic form when you are done with completing it. Your information is well-protected, because we keep to the most up-to-date security criteria. Join numerous satisfied users who are already submitting legal templates right from their homes.

Get form

Experience a faster way to fill out and sign forms on the web. Access the most extensive library of templates available.

Video instructions and help with filling out and completing tb screening questionnaire form

Our video guideline regarding how to complete Form on the web will help you get the done work quickly and error-free. Don't worry, it takes only a couple of minutes from beginning to end.

Tb questionnaire pdf FAQ

Get This Form Now!

Use professional pre-built templates to fill in and sign documents online faster. Get access to thousands of forms.

Ensure the security of your data and transactions

USLegal fulfills industry-leading security and compliance standards.

  • VeriSign logo picture

    VeriSign secured

    #1 Internet-trusted security seal. Ensures that a website is free of malware attacks.

  • Norton logo picture

    Norton Secured

    The highest level of recognition among eCommerce customers.

  • Accredited Business

    Guarantees that a business meets BBB accreditation standards in the US and Canada.

  • TopTenReviews logo picture

    TopTen Reviews

    Highest customer reviews on one of the most highly-trusted product review platforms.