Health Questionnaire Form – Fill Out and Use This PDF

The Health Questionnaire Form is an essential tool used by healthcare professionals to better understand the patient and optimize their treatment plan. It prompts questions such as a patient's medical history, medications they take, and lifestyle habits. By tackling such topics within the questionnaire form and analyzing their answers, healthcare professionals benefit from obtaining vital information on the health assessment of their patients and improving patient care. From furthering the accuracy of diagnoses to quickly identifying high-risk patients and tailoring recommended prevention steps; this vital document can create beneficial opportunities for accurate diagnoses that result in improved overall wellness for an individual.

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.

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

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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)

❏	Pre-Placement	❏	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) : __________________________________________________

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 follow-up questionnaires only complete section 3.)

	Yes	No	Don’t Know
1.	❏	❏	❏	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? ____________________________________
2.
	❏	❏	❏	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?
*3.	❏	❏		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?

Health Questionnaire Form – Fill Out and Use This PDF

Health Questionnaire Form PDF Details

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