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    TB Questionnaire

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    aplesgjsk
    This document is a tuberculosis questionnaire for a student. It asks for information such as the date of any positive TB skin tests, symptoms of TB like coughing or weight loss, current medical conditions or treatments, and verification by a physician. The questionnaire will share the student's information with hospitals and agencies where the student does placements.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    TB Questionnaire

    Uploaded by

    aplesgjsk
    132 views1 page
    This document is a tuberculosis questionnaire for a student. It asks for information such as the date of any positive TB skin tests, symptoms of TB like coughing or weight loss, current medical conditions or treatments, and verification by a physician. The questionnaire will share the student's information with hospitals and agencies where the student does placements.

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    TB

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    This document is a tuberculosis questionnaire for a student. It asks for information such as the date of any positive TB skin tests, symptoms of TB like coughing or weight loss, current medical conditions or treatments, and verification by a physician. The questionnaire will share the student's information with hospitals and agencies where the student does placements.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    132 views1 page

    TB Questionnaire

    Uploaded by

    aplesgjsk
    This document is a tuberculosis questionnaire for a student. It asks for information such as the date of any positive TB skin tests, symptoms of TB like coughing or weight loss, current medical conditions or treatments, and verification by a physician. The questionnaire will share the student's information with hospitals and agencies where the student does placements.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    ImmuniTrax

    Student Name: _____________________________________________________ Date: ________________________

    Tuberculosis Questionnaire

    Please complete the form below if you have ever had a positive reaction to a Tuberculosis Skin Test.

    Date of first positive TB skin test: Measurement: mm

    Have you ever had TB? Yes No


    Were you treated with medication? Yes No
    Medication name: ________________________________
    Length of treatment: ______________________________
    Have you ever had BCG? Yes No

    Symptoms Review: do you have any of the following?


    Chronic cough? Yes No
    Persistent night sweats? Yes No
    Chronic fatigue? Yes No
    Involuntary weight loss? Yes No

    Are you being treated for any serious medical conditions? Yes No
    Please describe: _______________________________________________________________________________

    Are you under treatment of Prednisone, Cancer Chemotherapy, or X-Ray Therapy? Yes No
    Please describe: _______________________________________________________________________________

    Printed Name: _____________________________________________________________

    Signature: ________________________________________________________________

    I verify that the above information is correct.


    ______________________________________________________________________________________ ______________________________________________
    Signature of Physician/ Nurse Practitioner Print Name of Physician/ Nurse Practitioner

    Phone: _____________________ Address: ___________________________________________________________________________________________________


    City: ______________________________________________________________________ State: ______________________ ZIP: _____________________

    Agency/Clinic Providing Service: ____________________________________________________________________________________________________________


    This information will be released to hospitals and community agencies where students are placed.

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