TB Form Questionnaire

Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Pregnant*

NoYes

Phone Number

Area CodePhone Number

Date

Ever Had an Adverse Reaction to TB Skin Test*

NoYes

Ever Infected with TB les than 2 Years Ago*

NoYes

Undernourished/Underweight*

NoYes

End Stage Renal Disease, Diabetes or Silicosis*

NoYes

Immune Suppressed*

NoYes

HIV Infected*

NoYes

Contact with Known Infected Person w/TB*

NoYes

History of Substance Abuse*

NoYes

Told to have Scarring/Fibriosis on Chest X-Ray*

NoYes

Treated for active TB*

NoYes

Treated for latent TB*

NoYes

Ever had a TB blood test*

NoYes

Ever had a BCG vaccine*

NoYes

Positive reaction to TB test*

NoYes

Born out of USA*

NoYes

Lived out of US less than 5 years*

NoYes

Traveled/Lived out of USA in 2 years*

NoYes

Are you a Healthcare Worker*

NoYes

Volunteered/Worked in nursing home, prison or other residential instituion*

NoYes

Company

Comment to checked answers above:

Please check all that are applicable

I have received information about TB skin test. I had a chance to ask questions which were answered to my satisfaction. I agree to return in 48-72 hours to have the test read. I understand the risks and benefits of the TB skin test and request that the test be given to me. I understand that if I am symptomatic for TB or if the TB skin test is positive, results may be communicated to the physician with whom I will follow-up if medical care is needed.

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