Tb Screening Form PDF Details

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.

QuestionAnswer
Form NameTb Screening Form
Form Length1 pages
Fillable?Yes
Fillable fields20
Avg. time to fill out4 min 19 sec
Other namesprintable tb questionnaire, tb screening questionnaire form, tb forms, fillable pdf tb screening form

Form Preview Example

LEHIGH UNIVERSITY HEALTH & WELLNESS CENTER/ BETHLEHEM HEALTH BUREAU

TUBERCULOSIS (TB) SCREENING FORM

First Name _______________________________

Last Name _______________________________________

Student ID# ______________________________

 

Cell Phone _______________________________

E-mail___________________________________________

Date of Birth _____________________________

Country of Birth___________________________________

____Undergraduate _____Graduate_____ESL_____Other

________________________________________________________________________________________

PLEASE ANSWER THE FOLLOWING QUESTIONS:

 

 

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

 

 

 

areas with a high prevalence of TB as defined by the World Health Organization? Yes

No

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

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