LHC International Tuberculosis (TB) Risk Questionnaire
LHC 国际肺结核 (TB) 风险调查问卷
Last Name ( Family Name)
First Name (Given Name)
WID #（学生 ID）：__________________________________________________________________________________
Month, Day and Year you arrived in the U.S.A. _ Country of Birth ______________________________________
您到达美国的月份、日子、年份。/ / 出生国家/地区 _______________________________________________________
Month Day Year
月 日 年
Countries in which you have lived over 3 months: 从中生活 3 个月以上的国家/地区： ___________________ ____
___________________________________________________________________________________________________________
Dates you were in these countries 生活在这些国家/地区时的日期 __________________________________
Date of Birth 生日_______________________ Age: 年龄 __ ________________
Sex (circle one): Male Female 性别（圈上一个）：男 女
Race (check one): Caucasian/non-Hispanic ___ Hispanic ____ Black/African ____ Asian _____ MidEastern _____
种族（勾选一个）：高加索人/非西班牙裔 ______ 西班牙裔 ____ 黑人/非洲人 ______ 亚洲人 ____ 中东人 _________
Native Hawaiian/other Pacific Islander American Indian/Alaskan Native __ Other ___________________________
夏威夷土著/其他太平洋岛民 ____________ 美国印第安人/阿拉斯加土著 _______ 其他种族 ________________________
Local Address:当地地址：_________________________________________________________________________________
Local phone number当地电话号码:______________________ Email address电子邮件地址： ___________________ ____
Number of people in Manhattan residence: 曼哈顿住宅中的人数： _____ Ages (if children) 年龄（若是儿童）:_____
Dept, of Study/Major Professor所在学系/主修专业教授 _____________________
______________________________
List any long term illnesses and current medications列出所有长期疾病和正在服用的药物：: ____________________
________________________________________________________________________________________________________
DIRECTIONS: Circle Y for yes or N for no.
说明：对于肯定回答，请圈上“是”；对于否定回答，请圈上“否”。
1. Any past or present liver diseases or hepatitis? YI N
以前或现在是否患有肝病或肝炎？是/否
2. Have you had recent contact with a person known or suspected of having active TB disease? YI N
最近是否接触过确实或有可能患有活动性肺结核病的人？是/否
3. Have you ever had active tuberculosis disease? YI N
是否患过活动性肺结核病？是/否
4. Have you ever had a skin or blood test for tuberculosis? Y I N If yes, date: Results __________________
是否针对肺结核接受过皮肤或血液检测？是/否 如果接受过，检测日期是： _________ 检测结果是： ______________
Have you ever had a chest x-ray? Y / N If yes, date: __ Results __________________
是否接受过胸部 X 光检查？是/否 如果接受过，检测日期是： __________________________ 检测结果是：
5. If yes to either components of question 4, were you treated for tuberculosis disease or tuberculosis infec
tion because of that test or exam? YI N If treated, with what? For how long? _____________________
如果对问题 4 中的任何一问作出肯定回答，您是否已因为所作的检测或检查而得到肺结核病或肺结核感染治疗？是/否 如
果已得到治疗，用的是什么疗法？ _____________________________________ 治疗了多长时间？ _____________
6. Have you ever received BCG (TB) vaccine? Y I N If so, how many times? _______ Date of last BCG _________
是否接种过卡介苗 (TB)？是/否 如果接种过，有多少次？ ________________________ 最后一次接种卡介苗的日期：
7. Symptoms- Chest pain YI N Weakness or Fatigue YI N Shortness of Breath YI N
症状 - 胸痛 是/否 虚弱或疲倦 是/否 呼吸急促 是/否
Coughing up blood YI N Fever Y / N Chills Y / N Night sweats YI N Appetite loss/weight loss YI N Blood in u
rine YI N Prolonged cough for more than 3 weeks Y I N
咳血 是/否 发热 是/否 发冷 是/否 盗汗 是/否 食欲不振/体重减轻 是/否 尿血 是/否 P长期咳嗽，长于 3 个星期 是/
否
8. Any vaccines in the last 30 days? Y I N If yes, please list:
过去的 30 天中是否接种过疫苗？是/否 如果接种过，请列出： ____________________________________________
9. (Females Only) Pregnant? YI N First day of last normal menstrual period （仅针对女性）是否已怀孕？是/否 最后
一个正常经期的第一天是： _______________________________________________________________________________
Signature签名:_______________________________________________________ Date日期：_______________________________
This box for Nurse use only
此框中各栏仅由办公室填写
Form Reviewed by:_____________________________________________Date:___________________________________
Signature of Nurse
Comments:
Date:
T-Spot Ordered & Date to Be Drawn:
TST Skin Test Placed & Date:
7/2015
Yes
Yes
No
No
Date
Date