Wichita State University Student Health Services Tuberculosis Evaluation Form

Download a blank fillable Wichita State University Student Health Services Tuberculosis Evaluation 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 Wichita State University Student Health Services Tuberculosis Evaluation 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.

Wichita State University Student Health Services Tuberculosis Evaluation

Family Name/Last

First Name(s)/Given Name(s)

Middle Name(s)

myWSU ID#

Name/Surname

(

)

Birth Date (MM/DD/YY)

Local Street address (ex: 4000 E. 17

St., #9 Wichita, KS 67208)

Phone Number

Field of Study (i.e. nursing, education, PT etc.)____________________________________________

Every section must be completed. Please mark all that apply. If nothing applies, mark “None.”

Section A (Personal History)

Gender

Race

Ethnicity

 Male

 American Indian

 Asian

 Pacific Islander

 Hispanic or Latino

 Female

 Black

Alaskan Native

 White

 Race not otherwise specified

 Not Hispanic or Latino

 Born in USA

 If not born in the USA, Country of Birth (specify) _____________________ Arrival Date in USA: ____________

Country of

Birth and

Travel

Have you ever traveled outside the USA?

 No  Yes If yes, where? ________________________________ For how long? _____________________

History

Have you resided in another country for more than three months?

 No  Yes If yes, where? _________________________________When? ___________________________

Section B (Medical History and TB Risk Factors)

Have you:

 ever had a positive TB test

 ever taken medication for tuberculosis date________how long_______

 ever had a positive Quantiferon blood test

 been in contact with a person who has active TB

 ever had a BCG vaccine

 had a viral infection (ex. chickenpox) in the last 30 days

 ever had a chest x-ray due to a positive TB test

 received immune globulin in the past three months

 recently completed or are currently on corticosteroid or immunosuppressive therapy (like chemotherapy)

 received a measles, mumps, rubella, yellow fever, varicella, or Flu-Mist vaccine in the last 30 days

 None

In the past year have you lived, worked, or volunteered in

 health care facility

 long term care facility

 child care facility

 correctional facility

 mycobacteriology lab

 rehabilitation center

 None

 homeless shelter

Section C (Review of Symptoms) Are you having any of these symptoms right now:

 Productive cough (lasting longer than 3 weeks); Date of onset ____/____/____

Blood in urine

 Weight loss

 Pain in the chest

 Coughing up blood or sputum

 Shortness of breath

 Swollen lymph glands of the neck, axilla, groin, etc.

 Night sweats

 Fever (recurrent)

 None

 Fatigue (severe)

I consent to this paper/electronic screening for TB. If SHS determines that I need further testing, I also consent to receiving TB testing and chest x-rays as

needed to screen for TB. I understand that if I am considered by SHS to be a high-risk student, I am not to attend any classes until my TB evaluation is complete.

Submit

Patient’s Signature

Today’s Date

TB Intake Form 1/2015