Tuberculosis Symptom Screening Questionnaire
Please complete this questionnaire to help assess your risk for tuberculosis. Your responses will remain confidential and are used solely for screening purposes.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Have you experienced any of the following symptoms recently? Please select all that apply.
*
Persistent cough (lasting 2 weeks or more)
Coughing up blood
Fever
Night sweats
Unexplained weight loss
Fatigue
None of the above
If you have a cough, how long have you been experiencing it?
*
Please Select
Less than 2 weeks
2-4 weeks
More than 4 weeks
I do not have a cough
Have you ever been diagnosed with tuberculosis before?
*
Yes
No
Have you been in close contact with someone diagnosed with tuberculosis in the past year?
*
Yes
No
Not sure
Do you have any of the following risk factors? Select all that apply.
*
HIV infection or immunosuppression
Diabetes
Recent travel or residence in a country with high TB prevalence
None of the above
Other
Please rate the severity of your symptoms below.
*
Rows
None
Mild
Moderate
Severe
Cough
1
2
3
4
Fever
5
6
7
8
Night sweats
9
10
11
12
Weight loss
13
14
15
16
Fatigue
17
18
19
20
Date of Screening
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional comments or relevant medical history (optional)
Submit Screening
Should be Empty: