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Upon review of the responses to the questionnaire and discussion with the person for whom the tuberculosis evaluation is required, I recommend as follows: _____There is no indication this person has active tuberculosis currently. _____ Further evaluation, including a TB Skin Test, Interferon Gamma Release Assay or other
TUBERCULOSIS SCREENING QUESTIONNAIRE FORM. SECTION 1: INFORMATION/CONSENT . Mycobacterium tuberculosis (TB) is a disease which is carried through the air in small particles when people, who have active TB cough, sneeze, speak, or sing. It usually affects the lungs but can also affect the heart, kidneys, bones, and other organs of the body.
The Tuberculosis Skin Test is a way of identifying TB infection. You cannot get TB from the skin test. RISKS & POSSIBLE SIDE EFFECTS: If you have been exposed to TB in the past, swelling and redness may develop at the site of the test. A blister or scar may also result.
This form is to be used for persons who are required to have TB screening for employment, post-secondary educational institution admission, long term residential care admission, correctional facility intake, or fulfillment of other statute or regulation.
(1) have had a significant reaction to the tuberculin skin test; (2) have had a negative chest X-ray; and (3) need a record of their tuberculosis status. Preparation: To be completed by a licensed medical professional.
TB Screening Form – Please indicate if you have any of the following symptoms: Yes No Chronic Cough Yes No Unexplained weight loss Yes No Production of sputum Yes No Unexplained fatigue/tiredness If yes, what color of sputum: _____ Yes No Night sweats Yes No Blood-streaked sputum Yes No Fever
2 Απρ 2019 · Have you ever had a positive reaction to a TB test? Have you had chest x‐ay(s) related to a positive TB test? Is there anyone in your family with TB? Have you ever had close contact with active TB (including health care exposure)? Have you ever been treated with TB medication?
