Drug Allergies
Food Allergies
Environmental Allergies
Pregnant
N
N
N
N
Y
Y
Y
Y
TUBERCULOSIS (TB) ASSESSMENT/CLEARANCE
NEW and PREVIOUSLY TB SKIN TEST POSITIVE INDIVIDUALS
Name________________________________________
Today’s Date________________
Birth Date__________
Birth Country_______________ Current Country of Residence________________
Years in Current Country______________
Previous TB skin test (TST) WITH documentation:
No/Unknown
OR
Yes
Date______ Result:
Neg
Pos
Previous Positive TST WITHOUT documentation:
No/Unknown
OR
Yes
Date______ Result:
Neg
Pos
History of treatment of TB infection or disease:
TB Signs/Symptoms Review:
Do you have any of these symptoms?
Quantaferon Gold Test Date_______
Result__________
No/Unknown
Treatment Dates:______________
OR
Yes
Fever N Y
Chills
N Y
Cough N Y
Productive Cough N Y
Weight Loss (≥10%)
N Y
Enlarged cervical lymph nodes
N Y
Night Sweats
N Y
Coughing up blood N Y
Other: ______________________________________________________
History of prior exposure to someone with TB disease:
No/Unknown
OR
Yes
Date_________
Exposure during medical procedure :
No/Unknown
OR
Yes
Date_________
Exposure in congregate (group) setting:
No/Unknown
OR
Yes
Date_________
Exposure in household of person with TB disease:
No/Unknown
OR
Yes
Date_________
History that may increase chance of prior exposure to someone with TB disease:
N
Y
N
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Residence or travel in country where TB is common Place/Dates:_______________________________________
(Mexico, Latin America, Caribbean, Africa, Eastern Europe, or Asia)
Resident or employee of correctional facility
Place/Dates:_______________________________________
Resident or employee of homeless shelter
Place/Dates:_______________________________________
Resident or volunteer in disaster shelter
Place/Dates:_______________________________________
Resident of long term care facility
Place/Dates:_______________________________________
Health care worker
Place/Dates:_______________________________________
Injection drug use
Place/Dates:_______________________________________
REFERRAL
Chest x-ray/Date:__________________
Results:__________________________ CXR Report Must be Attached to this form
Patient Cleared for TB, May Participate in Health Care Agency Clinicals:
NO
YES
Comments:_________________________________________________________________________________________________
Health-Care Provider Signature/Title: _________________________________
Health-Care Provider Printed Name/Title:______________________________
Office Address:____________________________________________ _____
Office Phone #:_____________________________
Revised September 2014 P.Shanaberger RN, FNP-C/M.Kaough RN, MSN, CCRN