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TB Screening Form

The document is a tuberculosis (TB) screening form for a student to complete which collects information about their symptoms, medical history, previous TB tests or treatment, and potential risk factors. It asks about cough, fever, weight loss and other symptoms; prior medical issues, medications, allergies and tests; as well as potential exposure to TB. The student must sign and date the completed form.

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BrianKo
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298 views1 page

TB Screening Form

The document is a tuberculosis (TB) screening form for a student to complete which collects information about their symptoms, medical history, previous TB tests or treatment, and potential risk factors. It asks about cough, fever, weight loss and other symptoms; prior medical issues, medications, allergies and tests; as well as potential exposure to TB. The student must sign and date the completed form.

Uploaded by

BrianKo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

*750*

*750*

TUBERCULOSIS (TB) SCREENING


(To be completed by student)

Name UIN

Country of origin e-mail address

Local address Local phone #

How long do you plan to stay in the USA?

List countries you have been to (besides your home country & USA)

Do you have any of the following symptoms?


Cough No Yes Loss of appetite No Yes Weakness No Yes
Fever No Yes Night sweats No Yes Weight loss No Yes

List any medical problems

Date of last chest x-ray Where was it done?

List medicines you take every day

List any allergies or adverse reactions to medications

Have you ever taken medicine for TB? ---------------------------------------------------------------------- No Yes


If yes, when? What kind of medicine?
How long?

Have you ever had the QuantiFERON-TB Gold Test? ---------------------------------------------------- No Yes
If yes, when Results: Negative OR Positive

Do you know anyone who has or had tuberculosis (family, friends, school friends, coworkers)? -- No Yes

Have you ever had any of the following:


Liver disease (hepatitis) ----------------------------------------------------------------------------------- No Yes
Steroids or immunosuppressive medications----------------------------------------------------------- No Yes
Chemotherapy or radiation therapy for cancer --------------------------------------------------------- No Yes
Immune deficiency disease ------------------------------------------------------------------------------- No Yes
Kidney disease---------------------------------------------------------------------------------------------- No Yes
Diabetes ----------------------------------------------------------------------------------------------------- No Yes
Lung disease (asthma, COPD) --------------------------------------------------------------------------- No Yes
Stomach or intestinal surgery----------------------------------------------------------------------------- No Yes
A blood transfusion ---------------------------------------------------------------------------------------- No Yes
Malnutrition or excessive weight loss------------------------------------------------------------------- No Yes

Student Signature Date


10/13/2011:bah

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