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. .