Patient Tuberculosis Risk Assessment printable pdf download

Patient Tuberculosis Risk Assessment

This form should be used for any client requesting tuberculosis testing, as a screening tool to document risk

prior to testing, and to determine whether testing is indicated.

FACILITY INFORMATION

Date____________________________

Facility/Clinic _____________________________________________________

Mailing address ________________________________________________

Phone _________________________________

City/State/Zip __________________________________________________

Fax ____________________________________

PATIENT INFORMATION

Name (last) ________________________________ (first) _________________________ DOB __________________ Sex ________

Occupation ____________________________________ Birth place  US  Other (please indicate) _________________________

Mailing address ________________________________________ City __________________ State _________ Zip ______________

Phone number _________________________________ Alternate contact/guardian ________________________________________

Race  Caucasian  Black/African American  Native American/Alaskan Native  Asian  Unkown  Other ________________

Ethnicity  Non-Hispanic  Hispanic/Latino

Social Security # _____________________________ (required for med assistance)

PREVIOUS TB SCREENING OR TREATMENT

Have you previously had a TB skin or blood test?  No  Yes, date of last test ________________ Result  Neg  Pos ______mm

Have you ever received treatment for TB disease or infection? No  Yes, please provide dates of treatment, location, and

medications ________________________________________________________________________________________________

Have you ever had a vaccine for TB (BCG)?  No  Yes, country and date of vaccine ____________________________________

In the last 30 days have you had a live viral vaccine such as MMR, chickenpox, flu, yellow fever?  No  Yes, date_____________

CONSENT FOR SCREENING AND TREATMENT

In accordance with state law, positive test results may be reported to the Wyoming Department of Health (WDH). As required by

HIPAA law, WDH may not further use or disclose protected health information without an authorization.

Acknowledgement of Receipt of Notice of Privacy Practices: I have received and read the WDH notice of privacy practices and have

had a chance to ask questions about how my information will be used.

Signature of client (or guardian) _____________________________________________________ Date _______________________

**The remainder of this document needs to be reviewed by a nurse or other clinician.**

TB SYMPTOM ASSESSMENT

A symptom review should be done with every client. Symptoms increase the risk of TB infection or progression to disease but should

be evaluated in context.

Prolonged cough (>2-3wks) with or

Diagnosis of community-acquired

without sputum production that may be

pneumonia that has not improved

bloody

after 7 days of treatment

Chest pain

Unexplained weight loss

Chills

Weakness or easily fatigued

Fever

Loss of appetite

Night sweats

Other ________________________

Nurse/Clinician Initials _____________ Date ____________

WDH TB Program • December 2016

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Patient Tuberculosis Risk Assessment

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