Get Va Vdh Tb Intake Sheet 2014-2025

The VA VDH TB Intake Sheet is an essential document for individuals undergoing tuberculosis evaluation. This guide provides clear and supportive instructions on how to accurately fill out the form online, ensuring that vital information is captured efficiently and correctly.

Follow the steps to complete the TB Intake Sheet online:

1. Click ‘Get Form’ button to obtain the VA VDH TB Intake Sheet and open it for filling.
2. Begin by entering your last name in the designated field, followed by your first name and middle initial, if applicable.
3. Provide your date of birth in the specified format, followed by your race and sex. Fill out your marital status next.
4. If applicable, enter the name of your parent or guardian in the section provided.
5. Complete your home address by filling in the street address, apartment number, city, state, and zip code.
6. Input your contact numbers, including home, work, and cell phone.
7. Fill in your country of origin and the year of arrival in the United States, along with your preferred language for communication.
8. Enter the name of your healthcare provider and their contact number.
9. Specify the reporting source and the reporter's contact number.
10. Review the symptoms section, checking all that apply to you, such as cough duration or weight loss.
11. Provide your weight and height in the designated fields.
12. Indicate whether initial blood work has been done and if results are available.
13. If applicable, fill out the details about the TB skin test or IGRA result, including date given and date read.
14. Complete the current chest x-ray section, including location and whether results were negative or abnormal.
15. Indicate if you have been hospitalized and provide additional individual risk factors for infection.
16. Complete the table under current treatment regimen, detailing your prescribed medications, dosages, and treatment dates.
17. If relevant, note any additional comments regarding treatment, work, or living arrangements.
18. Indicate if you are a Class B immigrant/refugee, ensuring to provide an A number if applicable.
19. Finally, complete the clinician orders and provide the clinician signature line at the end of the document.
20. Review your completed VA VDH TB Intake Sheet, and when satisfied, save changes, download, print, or share the form as necessary.

Begin filling out the VA VDH TB Intake Sheet online today to facilitate your tuberculosis evaluation process.