Health Questionnaire Form PDF Details

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.

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?