Tuberculosis Symptom Screen Form printable pdf download

TUBERCULOSIS SYMPTOM SCREEN

Patient Name: ___________________________________ Date of Birth: ____ /____ /____ Gender: ❐ Male ❐ Female

MEDICAL INFORMATION:

Last Skin Test Date: _____/_____/_____Result: ________mm ❐ Positive ❐ Negative

TB Site: ________________

Place Skin Test Was Given: ____________________________ Provider Name: ________________________________

Chest X-Ray Date: _____/_____/_____ ❐ Normal ❐ Abnormal CT Scan Date: _____/_____/_____ ❐ Normal ❐ A bnormal

Has patient been treated for: Latent TB Infection (LTBI)? ❐ No ❐ Yes If Yes, number of months ______

Has patient been treated for: TB Disease? ❐ No ❐ Yes If yes, when? ____________ Where? _________________

Does patient have a cough?.............................................................................................................❐ No ❐ Yes

If yes, how long?

# Days______ # Weeks______ # Months______

❐ No ❐ Yes

What color is the mucus? _______________

Is patient coughing up blood?

Does patient have night sweats? .................................................................................................... ❐ No ❐ Yes

Does patient have fevers? ............................................................................................................... ❐ No ❐ Yes

Has patient lost weight without trying? ..........................................................................................❐ No ❐ Yes

Has patient been tired or weak? ..................................................................................................... ❐ No ❐ Yes

If yes, how long has it lasted?

# Days______ # Weeks______ # Months______

Does patient have chest pain? ........................................................................................................ ❐ No ❐ Yes

If yes, how long has it lasted?

# Days______ # Weeks______ # Months______

Does patient have shortness of breath? ......................................................................................... ❐ No ❐ Yes

If yes, how long has it lasted?

# Days______ # Weeks______ # Months______

Does patient know anyone who has these symptoms? .................................................................. ❐ No ❐ Yes

Name: _________________________________ Address __________________________ Phone ______________

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

Client knows to seek health care if symptoms of TB appear

Further action needed:



Isolated



Given surgical mask



Chest X-Ray is needed



Sputum samples are needed



Referred to Doctor/Clinic (Specify):



Other (Specify):

Person Completing Form: _____________________________________

Date Completed: ____/____/____

Tuberculosis Symptom Screen Form

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