Tb Screening Form – Fill Out and Use This PDF

Tb Screening Form is a quick and easy way to find out if you have latent TB infection.

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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.

Question	Answer
Form Name	Tb Screening Form
Form Length	1 pages
Fillable?	Yes
Fillable fields	20
Avg. time to fill out	4 min 19 sec
Other names	printable tb questionnaire, tb screening questionnaire form, tb forms, fillable pdf tb screening form

12

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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