Annual TB Symptom Assessment Sheet To Be Completed by your Primary Health Care Provider Name: DOB: Date: Address: Telephone Number: Program: Banner ID #: FOR HISTORY OF POSITIVE PPD: Date of last TB Symptom Assessment: Date of Positive PPD: Any symptoms of TB since last TB assessment? Yes No Any high risk history since last TB assessment? Yes No Any known exposures to infectious TB? Yes No If yes explain TB SYMPTOM ASSESSMENT: Cough? Hemoptysis? Night Sweats? Weight Loss? Sputum production? Fever/Chills? Chest Pain? Unexplained Fatigue? Pregnant? Diabetes? Kidney Disease? Hepatitis? COPD/Asthma? Immunosuppressed? BCG? Birth Country? Past Treatment for TB? Last CXR? Health Care Provider signature or stamp Return form to: 400 East Ave, Room 1240 Warwick, RI 02886 or fax to (401) 825-1077 Referral?