Md Tuberculosis Risk Assessment And Ppd Form
Download a blank fillable Md Tuberculosis Risk Assessment And Ppd Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Md Tuberculosis Risk Assessment And Ppd Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Patient Name:
/
/
Date:
month day year
MD Tuberculosis Risk Assessment
D.O.B.
MR#
and PPD Form
1.
Where was the patient born?
6.
Please check all that apply: Has the patient:
USA
Ever been homeless or lived / worked in a shelter
Mexico /South / Central America
Lived / worked in a nursing home
Asia
Ever been an inmate or worked in a jail / prison
SE Asia
Ever been a healthcare worker
Africa
Has the patient had any vaccinations recently?
What?____________________________
Eastern Europe
Ever drunk alcoholic drinks? How many a week?
Western Europe
none
1 - 4
4 – 6
>6
2.
If not born in USA. When did they arrive in the USA?
Ever used IV drugs? Any other drugs?
Within the past 2 years
What kind? ________________________
2-5 years ago
Ever had TB or been treated for active or latent TB?
More than 5 years ago
NONE of the above
3. Has the patient ever had a skin test for Tuberculosis?
7.
Has the patient had contact with/lived with persons
Yes
No
Not Sure
Sick with Tuberculosis?
That were born or travel frequently outside of the
If YES, Where: ______________________________
USA. Where? _______________
(Clinic, Hospital, School, Etc…)
That use drugs or drink alcohol?
When: _____\_____\_____
NONE of the above
day
month year
Result:
Positive
Negative
Not Sure
4. Has the patient ever had a chest x-ray?
8.
Does the patient have or have they ever had
any of these conditions:
Yes
No
Not Sure
If YES, Where: _______________________________
(Clinic, Hospital, School, Etc…)
Diabetes
When: _____\_____\_____
Immune system disorder (e.g. leukemia, lymphoma)
day
month year
Steroid treatment for > than 2 weeks
Received chemotherapy for cancer
Silicosis or lung disease from mining / sand blasting
5. Tuberculosis usually causes one or more of these
Kidney failure that required dialysis
symptoms. Does the patient have any of the following:
Organ transplant or blood transfusions
Weight loss without trying, poor appetite and /or
Cough for longer than three weeks
Fevers
poor nutrition, weight >10% below ideal
Night Sweats
Fatigue
Ever had a positive test for HIV infection or AIDS
Loss of Appetite
Other
NONE of the above
Loss of Weight
NONE
TB Testing recommended?
NO
low risk and active TB not suspected
Risk assessment reviewed by
NO
documented prior positive PPD or prior TB diagnosis
(provider): ________________________
YES
Type of
Test Placed
Lot Number/Brand
Test Read
Size
Test
Date
Site/Signature
(Aplisol/Tubersol)
Date
Site/Signature
mm
PPD Skin
/
/
/
/
Test
2 Step
/
/
/
/
PPD
Repeat
/
/
/
/
PPD
Based on the induration and above history the PPD is:
Negative
Positive
CXR recommended? (If active TB is suspected do CXR - don't wait for PPD result, may be false negative)
/
/
/
/
YES
CXR appointment date
Date CXR done
NO
CXR Location: __________________
Reviewed by: (Provider signature)________________________________________
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical