Tuberculosis Risk Questionnaire (“TB Assessment Form”) Patient Name * First Name Last Name Birthday MM DD YYYY Does the patient have any of the following symptoms? If none, click "None" * Fever Coughing up blood Unexplained weight loss Unusual weakness Night time sweats Fatigue NONE Was this person BORN in a country with elevated TB rate such as the Philippines? * Low risk countries: US, Canada, Australia, New Zealand, Europe Yes (Will need TB test) No Has patient LIVED or VISITED a country with elevated TB rates for MORE THAN 4 WEEKS (such as the Philippines)? * YES (Needs TB test) No Has patient been EXPOSED to someone known to have TB with active symptoms? * Yes (Needs TB test) No Does patient have problems immune system problems? * Examples: Cancer, Rheumatological diseases, chronic steroid use for a month or longer, history of organ transplant, using immunosuppressant mediations Yes (Needs TB test) No If the patient is less than 16 years old, is anyone in the house from a country with elevated TB (such as the Philippines)? * Yes (needs TB test) No Not applicable, patient is over 15 years old Name of person filling out this form * First Name Last Name Email * Best phone number to reach you if we have questions * (###) ### #### Submitted. Thank you!If you answered “YES” to any of these questions, please call the clinic to schedule an appointment for a TB test. Patient will need to come back in 2-3 days afterwards for TB test reading.
