Health Questionnaire Form PDF Details

Are you looking for a comprehensive health questionnaire form to assist in gathering important information about your patients’ health history? Using a proper questionnaire form is essential in providing the best possible care and helping each patient achieve maximum well-being. A thorough health questionnaire can identify certain risk factors that may need to be addressed and serve as an invaluable tool when implementing a healthcare plan. Here, we review what should be included in such forms and offer advice on how medical professionals can create effective, individualized questionnaires for their patients.

Form NameHealth Questionnaire Form
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesprintable tb questionnaire, tb questionnaire form, tb skin test questionaire, health tb test questionnaire

Form Preview Example


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 Follow-up

Annual / Semi-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) : __________________________________________________


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.






Malabsorption Syndrome

Immune deficiency

Renal disease

Recent gastrectomy


Date Applied


Applied by


Date Read

(mm induration)

Read by

1st step



__________________ R

L ____/____/____

_____mm __________________




__________________ 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 follow-up questionnaires only complete section 3.)




Don’t Know



Have you ever had a positive TB test? If yes, when_____________________________________


Have you ever been treated with INH to prevent TB? If yes, for how long? __________________


Have you ever received the BCG vaccine?


Have you ever had an abnormal chest x-ray? When? ____________________________________







Have you ever been told you have Infectious Tuberculosis? If yes, how long ago?_____________


Have you ever been treated with medication for Infectious TB?



Did you take all the TB Medicine until the physician told you that you were finished?



Do you currently have a cough that has lasted longer than three weeks?



Do you cough up blood or mucous?



If yes, have you recently had the mucous you cough up tested for TB?



If yes, were you told it was positive?



Have you had a decrease in your appetite? Aren’t hungry?



Have you lost weight (over 10 pounds) in the last 2 months without trying?



Do you have night sweats (need to change the sheets or your clothes because they are wet)?


Do you live with or have you been in close contact with someone who was recently diagnosed





with TB (e.g. roommate, close friend, relative)?

Have you been diagnosed with Infectious TB since completing your last TB questionnaire?