Annual Tuberculosis Symptom Review Form

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Annual Tuberculosis Symptom Review Form
This form is required only of those with a history of positive PPD or other positive TB test result
Submit directly to the Compliance Office: A102
Fax to: 617-690-3730
(secure fax)
Student name
Email to: laboure_compliance@laboure.edu
Are you exhibiting any of the following symptoms of TB now, or within the past 12
months?
Yes
No
Fever?
Night Sweats?
Chronic fatigue?
Coughing up blood?
Involuntary weight loss?
Cough lasting longer than 3 weeks?
If you answered "yes" to any of the above symptoms, please explain how the
symptoms began and how long they lasted.
___________________________________________________________________
___________________________________________________________________
Have you ever had an x-ray done to rule out TB? If yes, when the x-ray was done.
___________________________________________________________________
___________________________________________________________________
Have you been treated for TB? If yes, what was the treatment and when?
___________________________________________________________________
___________________________________________________________________
This symptom review is valid of one year. Please complete and submit yearly.
Print name: _______________________________
Signature: ________________________________
Date: _______________

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