Form Rfa 08 - Tuberculosis (Tb) Screening Questionnaire
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1
2Resource Family Approval (RFA)
TUBERCULOSIS (TB) SCREENING QUESTIONNAIRE
for
__________________________
County or Agency
Instructions: To be completed by each adult residing in an Resource Family home and reviewed and signed by a licensed
health professional.
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Patient Name: ____________________________________ Date of birth: __________
Male
Female
Address: ___________________________________________________________________________________________
Street
Apartment #
City
Zip code
Telephone: _________________________________________________________________________________________
Home
Work
Cell
Country of birth: _______________ Race/Ethnicity: ____________ US arrival date (if applicable): ____________________
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Travel outside the United States in the last 2 years: ............................
Yes
No If yes list country________________
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Visitors from outside the United States in the last 2 years:..................
Yes
No If yes, list country________________
Please check one answer or fill in the blank:
1. Have you ever had a Bacille Calmette-Guérin (BCG) vaccine for tuberculosis
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(TB) disease?............................................................................................................
Yes
No
Unknown
a. BCG dates: __________________________________________________________________________
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2. Have you ever had a TB skin test?............................................................................
Yes
No
Unknown
If YES, please provide:
a. TB skin test date(s):____________________________________________________________________
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b. TB skin test results................................................................
Negative
Positive
Unknown
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3. Have you ever been told that you had TB infection or disease? ...............................
Yes
No
Unknown
I
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4. Did you ever take TB medication? ............................................................................
Yes
No
Unknown
If YES, please provide:
a. Name of the medication(s), number of pills and dates of treatment:
______________________________________________________________________________________
b. Name of clinic where you were treated? ____________________________________________________
5. Do you currently have any of the following signs and symptoms of active TB disease?
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a. Persistent cough longer than two weeks duration…………………………
Yes
No
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b. Coughing up blood……………………………………………………………
Yes
No
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c. Hoarseness……………………………………………………………………
Yes
No
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d. Fever……………………………………………………………………………
Yes
No
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e. Sweating at night……………………………………………………………...
Yes
No
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f. Unexplained weight loss……………………………………………………..
Yes
No
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g. Unexplained excessive fatigue………………………………………………
Yes
No
h. Other unusual symptoms:_____________________________________________________
TB SCREENING QUESTIONNAIRE
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