Tuberculosis (Tb) Symptom Screen Form
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1Tuberculosis (TB) Symptom Screen
Name: _____________________________________________ Sex: M / F
Date of Birth: _________________
Last skin test: ______________________________________________________________________________________
(Name, address, city, state, zip, and phone number of place where test was given)
Test date: ______ Results___mm Positive __ Negative __
Chest x-ray Normal ___ ____
Abnormal ___________
Were you treated for:
Latent TB Infection (LTBI) Yes/No
If yes, # of months treated: _____________
TB Disease Yes/No
If yes, # of months treated: _____________
When/Where _________________________________ __________________________________
Medications used ________________________________________________________________
Today’s Date __________
Do you currently have or have had any of the following in the past few months?
Cough:
Yes / No
If yes, for how long? __________________
Are you coughing up blood? Yes / No
If you produce mucus, what color ________
Night sweats:
Yes / No
Fever:
Yes / No
Weight loss:
Yes / No
If yes, how many pounds? ______________
Weakness:
Yes / No
If yes, how long? ______________________
Chest pain:
Yes / No
If yes, how long? ______________________
Short of breath: Yes / No
If yes, how long? ______________________
Do you know anyone who has these symptoms?
Yes / No
If yes, what are their name, address, and phone number? ____________________________________________________
Action taken (check all that apply)
No sign of active TB at this time
Chest X-Ray not needed at this time
Discussed signs and symptoms of TB with client
Instructed client to seek health care if begin having TB symptoms
Patient chose to decline LTBI medication at this time
Patient chose to begin LTBI medication at this time
Additional measures needed at this time:
Isolation
Given surgical mask
Chest x-ray needed at this time
Sputum samples collected
Referred to physician/clinic (specify):
Other:
Signature of person conducting the assessment ______________________________________________________
Signature of client __________________________________________
Date _______________________
GA DPH Unit
Revised 02/2015
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