Have you ever had a chest x-ray? If so, you may be familiar with the TB screening form that is usually given to patients. This form is used to screen for tuberculosis (TB), a serious respiratory infection. Although TB is not as common in the United States as it is in other parts of the world, it still poses a significant threat to public health. In this blog post, we will discuss the basics of TB screening and how it can be used to protect your health. We will also explore some of the myths and misconceptions about TB screening.
This figure offers specifics of tb screening form. Before you decide to complete the form, it can be definitely worth reading more details on it.
| Question | Answer |
|---|---|
| Form Name | Tb Screening Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | bureau tuberculosis screening form, printable tb questionnaire, tb forms, tb screening questionnaire form |
LEHIGH UNIVERSITY HEALTH & WELLNESS CENTER/ BETHLEHEM HEALTH BUREAU
TUBERCULOSIS (TB) SCREENING FORM
First Name _______________________________ |
Last Name _______________________________________ |
Student ID# ______________________________ |
|
Cell Phone _______________________________ |
|
Date of Birth _____________________________ |
Country of Birth___________________________________ |
____Undergraduate _____Graduate_____ESL_____Other
________________________________________________________________________________________
PLEASE ANSWER THE FOLLOWING QUESTIONS: |
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1. |
Have you ever had a positive TB (Tuberculosis) skin test (PPD)? |
Yes |
No |
2. |
Have you ever had a positive TB blood test (Quantiferon GOLD)? |
Yes |
No |
3. |
Have you ever had close contact with anyone who was sick with TB? |
Yes |
No |
4. |
Were you born in one of the countries listed below? |
Yes |
No |
5. |
Have you ever had an extended stay, 6 months or more, in any of the following |
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|
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areas with a high prevalence of TB as defined by the World Health Organization? Yes |
No |
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∙Africa – all countries
∙Asia/Southeast Asia/Pacific Islands – all countries
∙North, Central & South America – Argentina, Bahamas, Belize, Bolivia, Brazil, Costa Rica, Columbia, Dominican Republic, Ecuador, El Salvador, Guatemala, Guyana, Haiti, Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Suriname, Venezuela
∙Europe – Belarus, Bosnia, Herzegovina, Bulgaria, Croatia, Estonia, Hungary, Latvia, Lithuania, Macedonia, Moldova, Poland, Portugal, Romania, Russian Federations, Serbia, Slovak Republic, Slovenia, Ukraine, Yugoslavia
∙Middle East – Bahrain, Iran, Iraq, Israel, Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, Syrian Arab Republic, Turkey, Yemen
KRS 03/08/12