LHC International Tuberculosis (TB) Risk Questionnaire
Last Name (Family Name)
First Name (Given Name)
WID # (student ID):
Month, Day and Year you arrived in the U.S.A.
/
Month
/
Day
Country of Birth
Year
Countries in which you have lived over 3 months:
Dates you were in these countries
Date of Birth:
Age:
Race (check one): Caucasian/non-Hispanic
Native Hawaiian/other Pacific Islander
Sex (circle one):
Hispanic
Male
Black/African
American Indian/Alaskan Native
Female
Asian
MidEastern ____
Other
Local Address:
Local phone number:
Email address:
Number of people in Manhattan residence:
Ages (if children):
Dept. of Study/Major Professor
List any long term illnesses and current medications:
DIRECTIONS: Circle Y for yes or N for no.
1. Any past or present liver diseases or hepatitis? Y / N
2. Have you had recent contact with a person known or suspected of having active TB disease? Y / N
3. Have you ever had active tuberculosis disease? Y / N
4. Have you ever had a skin or blood test for tuberculosis? Y / N If yes, date:
Results
Have you ever had a chest x-ray? Y / N If yes, date:
Results
If yes to either components of question 4, were you treated for tuberculosis disease or tuberculosis infection because
of that test or exam? Y / N If treated, with what?
For how long?
6. Have you ever received BCG (TB) vaccine? Y / N
If so, how many times?
Date of last BCG
7. Symptoms-Chest pain Y / N
Weakness or Fatigue Y / N Shortness of Breath Y / N
Coughing up blood Y / N
Fever Y / N
Chills Y / N
Night sweats Y / N
Appetite loss/weight loss Y / N
Blood in urine Y / N
Prolonged cough for more than 3 weeks Y / N
8. Any vaccines in the last 30 days? Y / N If yes, please list:
9. (Females Only)
Pregnant? Y / N
First day of last normal menstrual period
Signature:
Date:
This box for office use only
Form Reviewed by: ___________________________________________ Date: ____________________
Signature of Nurse
Comments: ____________________________________________________________________________
______________________________________________________________________________________
IGRA Ordered & Date to Be Drawn: Yes No Date _______
TST Skin Test Placed & Date:
Yes No Date _______
_________________________________________________________________________________________________
Name – Last
First
Middle
WID#
pp 7/20/15 International TB Questionnaire 7-2015