Pediatric Tuberculosis (TB) Screening Questionnaire Form
Please complete this form to help assess your child's risk for tuberculosis (TB) exposure and symptoms. All information is confidential and used for medical screening purposes only.
Child's Full Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Country of Birth
*
Please Select
United States
Mexico
India
China
Philippines
Other
Has your child ever lived or traveled for more than one month in a country with a high rate of TB?
*
Yes
No
Not sure
Has your child had close contact with anyone diagnosed with active TB disease?
*
Yes
No
Not sure
Does your child have any of the following symptoms? (Select all that apply)
*
Persistent cough (lasting more than 2 weeks)
Unexplained fever
Night sweats
Unexplained weight loss or failure to gain weight
None of the above
Has your child ever had a positive TB skin test (TST) or TB blood test (IGRA)?
*
Yes
No
Not sure
Has your child ever received treatment for latent or active TB infection?
*
Yes
No
Not sure
Does your child have any medical conditions that weaken the immune system (such as HIV, cancer, or medications that suppress immunity)?
*
Yes
No
Not sure
Parent/Guardian Consent: I confirm that the information provided is accurate to the best of my knowledge and consent to TB screening for my child.
*
I consent
I do not consent
Submit Screening
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