The Health Questionnaire form, pivotal in tracking an individual’s health history and potential exposure to tuberculosis (TB), serves as a crucial tool in preventive healthcare practices, especially within occupational and employee health centers. It begins by collecting personal information, including social security number, date of birth, and the reason for screening, which ranges from pre-placement and initial exposure to post-exposure follow-up and annual or semi-annual screenings. The form intricately connects TB testing, including skin tests and health history questions, with factors that might affect the results, such as recent surgeries or significant changes in physical appearance that could alter the fit of a TB mask. Furthermore, it dives into specifics, inquiring about past medical treatments like chemotherapy or steroids, which could influence TB test outcomes. Additionally, it seeks information on historical health data related to TB, including previous positive tests, treatments, vaccinations, and symptoms experienced, ensuring a comprehensive evaluation of the individual's health status. This form not just meticulously logs medical conditions that necessitate a nuanced interpretation of TB skin tests but also delineates instructions for those with a history of positive TB reactions, guiding them through a tailored set of questions. By integrating detailed health assessments and TB testing protocols, the Health Questionnaire form embodies a systematic approach to monitoring and mitigating TB risks in occupational settings, highlighting the intertwined nature of personal health history and workplace safety measures.
| Question | Answer |
|---|---|
| Form Name | Health Questionnaire Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | printable tb questionnaire, tb questionnaire form, tb skin test questionaire, health tb test questionnaire |
TB TEST/HEALTH HISTORY QUESTIONNAIRE
Advocate Occupational and Employee Health Centers
Name________________________________________________SS#___________________________Date _____/_____/_____
(please print)
Facility_________________________________________Dept Rotating With______________________DOB_____/_____/_____
REASON FOR SCREENING (Test or Questionnaire)
❏ |
❏ |
Initial Exposure |
❏ |
Post Exposure |
|
❏ |
Annual / |
❏ |
Post Exposure Baseline |
❏ |
Other _______________ |
FIT TESTING (for those who have been fit tested for the TB mask)
Since your last fit test for the TB mask or respirator, check all that apply which may have altered the fit of your mask:
❏ |
New scarring on face (injury or surgery |
❏ |
Facial fracture (nose, jaw, cheek) |
❏ |
Significant weight loss or gain (over 10 lbs.) ❏ |
Have obtained dentures |
|
❏ |
Have grown a beard or mustache |
❏ |
Plastic surgery on face |
❏ |
Neurologic deficit (Bell’s palsy, stroke) |
❏ |
No Change |
Rotating Associate Signature (required) : __________________________________________________
PPD TESTING
Have you taken steroids or chemotherapy in the past 6 weeks?❏ Yes_______________________ ❏ No
People who have the following diseases are considered to have a positive TB skin test if induration is 5 mm or greater in size. Have you been diagnosed as having any of the diseases listed below? Check all that apply.
❏ |
Diabetes |
❏ |
Cancer |
❏ |
Alcoholism |
❏ |
Silicosis |
❏ |
Hodgkin’s |
❏ |
Malabsorption Syndrome |
❏ |
Immune deficiency |
❏ |
Renal disease |
❏ |
Recent gastrectomy |
|
Date Applied |
Lot# |
Applied by |
Site |
Date Read |
(mm induration) |
Read by |
|
1st step |
____/____/____ |
_________ |
__________________ ❏ R |
❏ L ____/____/____ |
_____mm __________________ |
|||
2nd |
____/____/____ |
_________ |
__________________ ❏ R |
❏ L ____/____/____ |
_____mm __________________ |
|||
TB test must be read by the Employee Health Center or a TB Liaison 48 to 72 hours after test is placed.
TB HEALTH HISTORY QUESTIONS (For those with history of positive TB reaction, record the following history but DO NOT RETEST! For
|
Yes |
No |
Don’t Know |
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1. |
❏ |
❏ |
❏ |
Have you ever had a positive TB test? If yes, when_____________________________________ |
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❏ |
❏ |
Have you ever been treated with INH to prevent TB? If yes, for how long? __________________ |
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❏ |
❏ |
❏ |
Have you ever received the BCG vaccine? |
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❏ |
❏ |
❏ |
Have you ever had an abnormal chest |
2. |
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❏ |
❏ |
❏ |
Have you ever been told you have Infectious Tuberculosis? If yes, how long ago?_____________ |
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❏ |
❏ |
❏ |
Have you ever been treated with medication for Infectious TB? |
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❏ |
❏ |
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Did you take all the TB Medicine until the physician told you that you were finished? |
*3. |
❏ |
❏ |
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Do you currently have a cough that has lasted longer than three weeks? |
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❏ |
❏ |
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Do you cough up blood or mucous? |
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❏ |
❏ |
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If yes, have you recently had the mucous you cough up tested for TB? |
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❏ |
❏ |
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If yes, were you told it was positive? |
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❏ |
❏ |
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Have you had a decrease in your appetite? Aren’t hungry? |
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❏ |
❏ |
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Have you lost weight (over 10 pounds) in the last 2 months without trying? |
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❏ |
❏ |
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Do you have night sweats (need to change the sheets or your clothes because they are wet)? |
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❏ |
❏ |
❏ |
Do you live with or have you been in close contact with someone who was recently diagnosed |
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with TB (e.g. roommate, close friend, relative)? |
❏ |
❏ |
Have you been diagnosed with Infectious TB since completing your last TB questionnaire? |