Schedule Appointment

Please review and answer the following questions with the individual above:

1. Have you had a history of temporary or permanent residence (for > 1 month) in a country with a high TB rate (i.e., any country other than Australia, Canada, New Zealand, the United States, and those in Western or Northern Europe) in the past year?
2. Have you ever been diagnosed with Latent TB infection (LTBI)?
3. Do you have a current or planned immunosuppression, including human immunodeficiency virus infection, receipt of an organ transplant, treatment with a tumor necrosis factor (TNF)-alpha antagonist (e.g., infliximab, etanercept, or other) chronic steroids (equivalent of prednisone > 15mg/day for > 1 month) or other immunosuppressive medication?
4. Have you had close contact with someone who has had infectious TB disease in the past year?
b. Did you have adequate personal protection when exposed?
5. Have you ever been treated for Latent TB infection (LTBI)?
6. Have you ever been diagnosed with TB infection (TB)?
7 . Have you ever been treated for TB infection (TB)?
8 . Have you had any prior diagnostic testing for TB disease?
9. Have you ever had a tuberculin skin test (TST)?
10. When was your last chest x-ray?
MM slash DD slash YYYY
11. Do you currently have any of the following symptoms?
Productive cough for more than 3 weeks
Productive cough for more than 3 weeks
Coughing up blood
Coughing up blood
Unexplained weight loss
Unexplained weight loss
Fever, chills, or drenching night sweats for no known reason
Fever, chills, or drenching night sweats for no known reason
Persistent shortness of breath
Persistent shortness of breath
Unexplained fatigue for more than 3 weeks
Unexplained fatigue for more than 3 weeks
Chest Pain
Chest Pain
This field is for validation purposes and should be left unchanged.
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