Adult Tb Risk Assessment
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3Adult TB Risk Assessment and Screening Form
(For Patient Record)
Name:
DOB:
Date:
TB Risk Assessment
Yes
No
1) Were you born in Africa, Asia, Central America, South America, Mexico, Eastern Europe,
Caribbean or the Middle East?
In what country were you born?
2) In the past 5 years, have you lived or traveled in Africa, Asia, Central America, South America,
Mexico, Eastern Europe, Caribbean or the Middle East for more than one month?
3) In the last 2 years, have you lived with or spent time with someone who has been sick with TB?
4) Do you have (or have you had) any of these medical conditions?
Diabetes
Kidney disease
HIV infection
Colitis
Cancer
Stomach or intestine surgery
Rheumatoid arthritis
5) Are you taking any medications that your doctor said could weaken your immune system or
increase your risk for infections?
6) In the past 1 year, have you injected drugs that your doctor did not prescribe?
7) Have you ever lived or worked in a prison, jail, homeless shelter or long-term care facility?
(example: nursing home, substance abuse treatment, rehabilitation facility)
Yes
No
Symptom Screening – At this time, do you have any of these symptoms?
1) Coughing for more than 2-3 weeks?
2) Coughing up blood?
3) Weight loss of more than 10 pounds for no known reason?
4) Fever of 100°F (or 38°C) for over 2 weeks?
5) Unusual or heavy sweating at night?
6) Unusual weakness or extreme fatigue?
Student Signature___________________________________________ Date:____________
If you answer “yes” to any of the questions above, you may be at increased risk for TB infection.
Please give this form to your medical provider.
Contact Email:_____________________________ Contact Number:___________________
Student ID#: ______________________
Massachusetts Department of Public Health / Bureau of Infectious Disease /
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Division of Global Populations and Infectious Disease Prevention
November 2013
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