Tuberculosis Information and Screening
Name_______________________________________________________ Date of Birth_______________
Last
First
Middle Initial
mm/dd/yyyy
CWID______________________ Where were you born? USA___ Other Country____________________
Name of Country
1. Have you ever had a positive Tuberculosis Skin or Blood Test (PPD, T-Spot or Quantiferon TB Gold)?
Date (month/year) ____________________
Please Check
Yes ☐
No☐
2. Have you ever been given medicine(s) to prevent or treat active Tuberculosis?
Yes ☐
If yes, date (mm/yyyy) ______________List Medication: _________________________For how long ________
No ☐
3.
Have you ever had a BCG (immunization for Tuberculosis)?
Yes ☐
No ☐
4.
Have you ever had close contact with a person with active Tuberculosis?
Yes ☐
No ☐
5.
Have you ever worked, volunteered or lived in a health care facility, long term care facility,
nursing home, jail/prison, or homeless shelter?
Yes ☐
No ☐
Are you from, or have you lived for two months or more in any of the high incidence of Tuberculosis
countries listed below? If yes, list countries ____________________________________________________ Yes ☐
No ☐
6.
Afghanistan, Algeria, Angola, Argentina, Armenia, Azerbaijan, Bangladesh, Belarus, Belize, Benin, Bhutan, Bolivia , Bosnia and Herzegovina, Botswana, Brazil,
Brunei Darussalam, Bulgaria, Burkina Faso, Burundi, Cabo Verde, Cambodia, Cameroon, Central African Republic, Chad, China, Columbia, Comoros, Congo, Congo
DR, Cote D’Ivoire, Djibouti, Dominican Republic, Ecuador, El Salvador, Equatorial Guinea, Eritrea, Estonia, Ethiopia, Fiji, Gabon, Gambia, Georgia, Ghana,
Guatemala, Guinea, Guinea-Bissau, Guyana, Haiti, Honduras, India, Indonesia, Iran, Iraq, Kazakhstan, Kenya, Kiribati, Korea DPR, Kuwait, Kyrgyzstan, Lao, Latvia,
Lesotho, Liberia, Libya, Lithuania, Madagascar, Malawi, Malaysia, Maldives, Mali, Marshall Islands, Mauritania, Mauritius, Mexico, Micronesia, Moldova,
Mongolia, Montenegro, Morocco, Mozambique, Myanmar, Namibia, Nauru, Nepal, Nicaragua, Niger, Nigeria, Pakistan, Palau, Panama, Papua New Guinea,
Paraguay, Peru, Philippines, Poland, Portugal, Qatar, Rep of Moldova, Romania, Russian Federation, Rwanda, Saint Vincent and the Grenadines, Sao Tome and
Principe, Senegal, Seychelles, Sierra Leone, Singapore, Solomon Islands, Somalia, South Africa, South Sudan, Sri Lanka, Sudan, Suriname, Swaziland, Tajikistan,
Tanzania (United Republic of), Thailand, Timor-Leste, Togo, Trinidad and Tobago, Tunisia, Turkey, Turkmenistan, Tuvalu, Uganda, Ukraine, United Rep of Tanzania,
Uruguay, Uzbekistan, Vanuatu, Venezuela, Viet Nam, Yemen, Zambia, Zimbabwe.
Source: Health Organization Global Health Observatory, Tuberculosis Incidence
2012. Countries with incidence rates of ≥ 20 cases per 100,000 population.
For future updates, refer to http://apps.who.int/gho/data/node.main.1320?lang=en
Yes ☐
Shortness of Breath ☐
Unexplained Weight Loss ☐
7.
Have you recently had any of the following symptoms for no known reason?
Check all that apply: Night sweats ☐ Fatigue/Tiredness ☐ Unexplained Fevers ☐
Poor Appetite ☐ Coughing up blood ☐ Productive cough for more than 3 weeks ☐
8.
Have you ever been diagnosed with a chronic medical condition that may impair your immune
system or for which you are taking medications that suppress your immune system?
(what condition or medication?) ____________________________________________________
Yes ☐
No ☐
No ☐
Patient’s Signature: __________________________________________________________________ Date ____________________
(Parent/guardian signature if under 18 years of age)
If you answered “YES” to any of questions 3 – 8, you must have a current Tuberculosis Skin Test (PPD) or IGRA test (the latter test
is preferable if you have had the BCG vaccine). If you have had a prior positive TB skin or blood test and have not undergone
treatment for latent or active TB disease, you must have a recent chest x-ray.
The following information must be completed by a Physician’s Office:
(check which test you have done)
☐ Tuberculin Skin Test (Mantoux only; no tine tests)
☐ T-Spot or Quantiferon TB Gold Blood Test
Date skin test placed: ___/___/___ Date read: ___/___/___ Result of skin test: __________mm
(Record actual mm of induration for TB skin test: if no induration, write “O”)
☐ Interferon Gamma Release Assay (IGRA)
Date obtained: ___/___/___
Method: QFT-G QFT-GIT T-Spot Other Result: Negative Positive Indeterminate Borderline (T-Spot only)
☐ Chest X-ray (required if Tuberculin skin test is positive): Date of chest x-ray: ___/___/___
Result: Normal
Abnormal
Physician/PA/NP/Public Health Signature: ______________________________________________ Date ______________________
Address:_____________________________________________________________________________________________________
Telephone Number: __________________________________________Fax Number: ______________________________________