Tuberculosis Questionnaire
Employee Section
(Please complete this section prior to clinical evaluation)
1. Have you ever had a positive PPD or Quantiferon?
Yes
No
2. Positive TB skin test (PPD) date
(OR)
Positive Quantiferon date
3. Last chest X-ray date
(copy of official report must be on files with EHS)
4. After the last positive TB screening, was INH therapy ever initiated?
Yes
No
a. What medications did you take?
b. When?
Duration
Why not?
Note: If you have not already followed up with an infectious disease specialist or your PCP after your last positive TB screening regarding the possibility of latent TB, we recommend you to do so.
Screening Questions
- please indicate if you are having any of the following symptoms:
1. Chronic cough or sputum production for longer than 3 weeks
Yes
No
2. Blood-streaked sputum
Yes
No
3. Unexplained weight loss or loss of appetite
Yes
No
4. Unexplained fever
Yes
No
5. Fatigue/tiredness or night sweats
Yes
No
6. Shortness of breath or chest pain
Yes
No
Signature
– by typing your full name below you are stating this will be accepted as your signature.
Date
*
First Name
*
Last Name
*
Date of Birth
*
Email
*