TB Screening Form
Patient Name
First Name
Last Name
Healthcare Professional Name
First Name
Last Name
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
1. In the last year, have you had any of the following symptoms?
Coughing for more than 3 weeks
Coughing up blood
Extreme weight loss
Fever
Shortness of breath
Unexplained fatigue
Chest pain
2. In the last year, have you had contact with anyone with tuberculosis disease?
Yes
No
Not sure
3. Do you have a medical condition?
Yes
No
What is your medical condition?
4. Are you under any medication?
Yes
No
What are your medications?
5. Why do you request a TB Screening Test?
Patient Signature
Healthcare Professional Signature
Submit
Should be Empty: