1. |
Have you
ever had a positive TB skin test? |
|
Yes |
No |
Don't
know |
|
2. |
Have you
ever had an abnormal chest x-ray? |
|
Yes |
No |
Don't
know
|
|
|
If yes, how
long ago? |
3. |
Have you
recently had the mucous you cough up tested for TB? |
|
Yes |
No |
Don't
know
|
|
|
If yes, were
you told it was positive? |
|
Yes |
No |
Don't
know |
|
4. |
Have you
ever been told you have Infectious Tuberculosis? |
|
Yes |
No |
Don't
know
|
|
|
If yes, how
long ago? |
5. |
Have you
ever been treated with medication for Infectious TB? |
|
Yes |
No |
Don't
know
|
|
|
If yes, how
may medications? |
|
One |
Two |
Over two |
|
6. |
Are you
still taking TB medicine? |
|
Yes |
No
|
|
|
|
Did you take all the TB
medicine until the health care professional told you that you were finished? |
|
Yes |
No |
|
|
7. |
Do you live with or have
you been in close contact with someone who was recently diagnosed with TB? (e.g. shelter
roommate, close friend, relative). |
|
Yes |
No |
Don't know |
|
CURRENT
SYMPTOMS (Part Two) |
1. |
Do you have
a cough that has lasted longer than three weeks? |
2. |
Do you cough up blood or
mucous? |
|
Yes |
No |
|
|
3. |
Have you lost your
appetite? Aren't hungry? |
|
Yes |
No |
|
|
4. |
Have you lost weight
(more than 10 pounds) in the last two months? without trying to? |
|
Yes |
No |
|
|
5. |
Do you have night sweats
(need to change the sheets or your clothes because they are wet)? |
|
Yes |
No |
|
|
Evaluator
Comments: |
Exposure Control
Methods Implemented? |
|
Yes |
No |
|
|
Referred for Further
Evaluation? |
|
Yes |
No |
|
|
Evaluator's
Signature:______________________________ |
Date:_____________ |