Schiffert Health Center - Tuberculosis Risk Assessment Form (Required)
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1SCHIFFERT HEALTH CENTER
TUBERCULOSIS RISK ASSESSMENT FORM (REQUIRED)
Date: _______________ ID#: ___________________Birth Date: _________________Email: ______________________________
Name (Last, First, Middle) ___________________________________________________________________________________
Address____________________________________________________ City: _________________________State:____________
Zip Code: ______________ Country of Origin: ___________________________________________________________________
History Risk:
1. Have you ever had a positive TB skin test? ____ No ____ Yes Date of Positive PPD: ______________ mm Induration _______
2. Have you had a QuantiFERON Tb Gold Test? ____ No ____ Yes Date: ______________ Result: ____ Positive ____ Negative
3. Have you had a T‐SPOT Tb Test? ____ No ____ Yes Date: ______________ Result: ____ Positive ____ Negative
CHECK THE BOX IF ANY OF THE FOLLOWING APPLY: A PPD or QFT‐G is required if any section is checked.
Current Symptoms:
Do you currently have any of the following symptoms? ___ NO If YES, check all that apply.
Persistent cough for more
Persistent night sweats
Loss of appetite
than 3 weeks
___ Yes
___ Yes
___ Yes
Fever or chills
Unexplained weight loss
Productive cough with
___ Yes
___ Yes
bloody sputum
___ Yes
Exposure Risks:
If yes to any question, a TB skin test and completed Tuberculosis Skin Testing Form is required.
1. Have you within the last 2 years, worked or volunteered (>8 hr/week) in the following types of facilities? ____ No ____ Yes
Homeless Shelter
Residential Facilities for patients
Prisons
Hospitals, Nursing
Long‐term Care
Rehab Facility
with AIDS
Homes
2. Have you recently come into contact with a person who has Tuberculosis? ____ No ____ Yes
3. Have you ever used any illegal injected drugs?
____ No ____ Yes
Health Risks:
Do you currently have any of the following conditions? ___ NO If YES, check all that apply.
Leukemia, lymphoma;
Gastrectomy, jejunoileal
Solid organ transplant
Cancers of head or neck;
bypass, chronic
(kidney, heart); On dialysis
___ Yes
___ Yes
___ Yes
Underweight or
malabsorptive conditions
or chronic renal failure
malnourished
Silicosis, Diabetes, HIV
Prolonged corticosteroid
On any TNF antagonist
Infection
therapy or other
medication (Humira, Embrel
___ Yes
___ Yes
___ Yes
Chemotherapy
immunosuppressive
or Remicade for RA or
disorders
Crohn’s Disease
Travel Risks:
Have you lived or traveled to any country in the following areas of the world for a duration of three (3) months or
more
within the past five (5) years? ___ YES (Check all that apply) ___ NO
___ India and other
___ Central America,
___ South Pacific (except
___ Middle East (except Egypt,
___ Cuba, Haiti,
Indian Subcontinent
including Mexico
Australia, New Zealand)
Saudi Arabia, Jordan ,Lebanon,
Dominican Republic
nations
UAE)
___ Asia
___ Africa
___ Eastern Europe
___ South America
___ Portugal
SUBMIT THIS FORM WITH THE IMMUNIZATION HISTORY FORM.
TB Risk Form 6/13
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