Tb Questionnaire Form – Fill Out and Use This PDF

The TB Questionnaire form is a critical document designed to screen individuals for tuberculosis (TB), helping healthcare professionals identify potential risks and symptoms related to TB. It includes personal information, a series of questions about health history, exposure to TB, and a consent to testing section. Discovering one's TB status is vital for both treatment and preventing the spread of this disease, making filling out this form an important step.

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Tb Questionnaire Form PDF Details

The TB Screening Questionnaire is a crucial tool used to identify individuals at risk for tuberculosis (TB) and determine the necessity for further testing. It begins by collecting basic personal information, including name, date of birth, contact details, and address, followed by a section where respondents are asked to circle any current symptoms they are experiencing such as cough, fever, night sweats, weight loss, tiredness, or coughing up blood. The form delves deeper with questions about the individual's TB history, asking if they've ever had a positive TB skin or blood test, reactions to previous tests, TB medication history, and potential exposure to the disease through contact with others who have TB. Additionally, it inquires about the respondent's birth country and vaccination history, specifically the BCG vaccine, and assesses risk factors including drug use, HIV/AIDS status, and the presence of other diseases that might impact the immune system, such as diabetes or severe kidney disease. The questionnaire rounds off with a consent to testing section, where the individual acknowledges understanding the procedure and agrees to return for result interpretation. For medical professionals, there's a space to document the administration and results of the TB skin test, highlighting the importance of timely and accurate assessment to manage and mitigate the spread of tuberculosis effectively.

Question	Answer
Form Name	Tb Questionnaire Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	tb questionnaire pdf, tb questionnaire form, tb questionaire, printable tb questionnaire

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TB SCREENING QUESTIONNAIRE

___________________	___________________	________________		____/_____/_____
Last name	First name	Middle name		Date of birth
______________________________________ _________________			___________	____________
Address		City	State	Zip
_____________________	_____________________		_____/_____/_____
Home phone	Cell or work phone		Today’s date

	CIRCLE ANY OF THE BELOW SYMPTOMS YOU HAVE TODAY
Cough	Coughing up blood	Fever	Weight loss		Tiredness		Night sweats
	PLEASE ANSWER THESE QUESTIONS

Why do you need a TB test today?

Have you ever had a positive TB skin test or TB blood test?				Yes		No	Don’t Know

Have you had a severe reaction to a TB skin test?				Yes		No	Don’t Know

Have you ever taken medication for tuberculosis?				Yes		No	Don’t Know

What country were you born in?

If you were not born in the U.S., when did you come here?

Have you had the BCG vaccine?				Yes		No	Don’t Know

Have you been in contact with someone who has TB disease?				Yes		No	Don’t Know

Have you ever used injection drugs?				Yes		No	Don’t Know

Do you have HIV/AIDS?				Yes		No	Don’t Know

Do you have any diseases that could affect your immune sys-				Yes		No	Don’t Know
tem such as cancer, leukemia or other?

Do you have diabetes?				Yes		No	Don’t Know

Do you have severe kidney disease?				Yes		No	Don’t Know

Are you underweight or do you have a disease which affects				Yes		No	Don’t Know
how you absorb food and nutrients?

Have you had an intestinal bypass or gastrectomy?				Yes		No	Don’t Know

Do you take any prescription medications? List them below:				Yes		No	Don’t Know

continue on next page

Name: ____________________________	_______________________________
Last	First

CONSENT TO TESTING

I have received information about the TB skin test. I had a chance to ask questions which were answered to my satisfaction. I agree to return in 48-72 hours to have the test read. I understand the risks and benefits of the TB skin test and request that the test be given to me. I understand that if I am sympto- matic for TB or if the TB skin test is positive, results may be communicated to the physician with whom I will follow-up if medical care is needed.

_____________________________________	_______________________
Signature	Date
DO NOT COMPLETE, FOR NURSE

TST #1

TST #2

	Administration

	Name of person giving test

	Date and time administered

	Location (circle)	L forearm	R forearm	L forearm	R forearm

	Tuberculin manufacturer

	Tuberculin exp. date and lot #

	Administrator signature

	Results (48-72 hours)

	Date and time read:

	Number of mm of induration:	______ mm		______ mm
	(across forearm)	______ mm		______ mm
	(across forearm)

	Interpretation of reading (circle)	Positive**	Negative	Positive**	Negative

	Reader’s signature

**Interpreting the TST

>5 mm is positive for:

HIV infected

Recent contacts

People with fibrotic changes on CXR

Patients with organ transplant and others on immunosuppressant drugs (including prolonged course of oral or intravenous corticosteroids or TNF alpha inhibitors)

>10 mm is positive for:

Recent immigrants (≤5 yrs) from high TB burden countries

Injection drug users Mycobacterial lab workers

People who live/work in high risk congregate settings (health care workers, long term care, correctional facilities) Children younger than 4 years

Infants, children and adolescents exposed to adults in high risk categories

People with:

Diabetes, severe kidney disease, silicosis, cancer of head

or neck, hematologic or reticuloendothelial disease such as Hodgkin’s disease or leukemia, intestinal bypass or

gastrectomy, chronic malabsorption syndromes, low body weight

>15 mm is positive if there are no known TB risk factors

How to Edit Tb Questionnaire Form Online for Free

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Step 2: Using our handy PDF tool, you can actually accomplish more than simply complete blank fields. Edit away and make your documents look great with customized textual content added in, or fine-tune the original input to perfection - all that supported by the capability to insert your own images and sign the document off.

This document will need some specific information; in order to guarantee accuracy, please make sure to pay attention to the next recommendations:

1. When filling out the annual tb screening questionnaire form, make sure to complete all needed fields in its corresponding area. It will help to facilitate the process, enabling your information to be processed without delay and appropriately.

Stage # 1 for filling out tb screening questionnaire

2. Once the last segment is done, you need to add the required details in Why do you need a TB test today, Have you ever had a positive TB, Have you had a severe reaction to, Have you ever taken medication for, What country were you born in, If you were not born in the US, Have you had the BCG vaccine, Yes, Yes, Yes, Yes, Have you been in contact with, Yes, Have you ever used injection drugs, and Do you have HIVAIDS so that you can move on further.

Filling in section 2 in tb screening questionnaire

3. This next segment should be relatively simple, Have you had an intestinal bypass, Do you take any prescription, Yes, Yes, Dont Know Dont Know, and continue on next page - all of these blanks will need to be filled in here.

Filling out segment 3 in tb screening questionnaire

4. The subsequent subsection requires your input in the following areas: First, Name Last CONSENT TO TESTING I, Date, Administration, Name of person giving test, Date and time administered, TST, TST, Location circle, L forearm R forearm, and L forearm R forearm. Make certain to give all required details to go further.

Filling out segment 4 of tb screening questionnaire

5. While you approach the final sections of this file, there are just a few more points to do. Notably, Location circle, L forearm R forearm, L forearm R forearm, Tuberculin manufacturer, Tuberculin exp date and lot, Administrator signature, Results hours, Date and time read, Number of mm of induration across, Interpretation of reading circle, Positive Negative, Interpreting the TST mm is, HIV infected Recent contacts, and People with fibrotic changes on must all be filled out.

Part number 5 of completing tb screening questionnaire

Always be extremely mindful while completing People with fibrotic changes on and Number of mm of induration across, since this is the section in which a lot of people make errors.

Step 3: Ensure your details are right and click on "Done" to proceed further. Try a free trial subscription with us and gain instant access to annual tb screening questionnaire form - download or edit in your FormsPal account page. FormsPal offers secure form editing without personal information record-keeping or any type of sharing. Rest assured that your details are safe with us!

Tb Questionnaire Form – Fill Out and Use This PDF

Tb Questionnaire Form PDF Details

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