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Consent-TuberculosisScreeningQuestionnaire

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Filipe Jorge
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18 views

Consent-TuberculosisScreeningQuestionnaire

Uploaded by

Filipe Jorge
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Tuberculosis (TB) Screening

Patient Name: _________________________________ Company: ____________________________________


Date of Birth: __________________________________ Company Contact: _____________________________
Patient Address: ________________________________ Company Phone: ______________________________
______________________________________________ Company Fax: ________________________________
Patient Phone: _________________________________ Bill to: Company Self
County of Residence: ___________________________ Initial Screening Annual Review
New Hire Position/Start Date: _____________________ First Step Second Step

History:
1. Have you ever spent more than 30 days in a country with an elevated TB rate? This includes all countries except those
in Western Europe, Northern Europe, Canada, Australia, and New Zealand.
Yes, I have been in a foreign country for greater than or equal to 30 days (no including those listed above)
No, I have not been in any country for greater than or equal to 30 days (except those listed above)
2. Have you had close contact with anyone who had active tuberculosis since your last TB test?
Yes: date ________
No
3. Have you ever been diagnosed with active tuberculosis disease?
Yes: date ________
No
4. Have you been diagnosed with latent tuberculosis infection or had a positive skin test or a positive blood test for
tuberculosis?
Yes, one or more of these is true for me
No, none of these is true for me
5. Have you been treated with medication for tuberculosis or for a positive TB test (example: taken “INH”)?
Yes: If yes, what year, with which medication, for how long, and did you complete the treatment course?
______________________________________________________________________________________________
No
6. Do you have a weakened immune system for any reason including organ transplant; recent chemotherapy; poorly
controlled diabetes; HIV infection; cancer; or treatment with steroids for more than one month, immune-suppressing
medications such as TNF-alpha antagonist, or another immune-modulator? (If you are not sure, ask your Occupational
Health provider.)
Yes, one or more of these is true for me
No, none of these is true for me
7. Have you received any vaccination within the last four weeks?
Yes: date ________
No
8. Have you ever received the BCG (immunization for tuberculosis)?
Yes: date ________
No
9. Have you ever received a Tuberculin Skin Test (TST)?
Yes: date ________
No

Do you currently have any of the following symptoms?


1. A cough that has lasted longer than three weeks with sputum production Yes No
2. Unexplained fever for more than three weeks Yes No
3. Bloody sputum Yes No
4. Unintended weight loss greater than 10 pounds Yes No
5. Drenching night sweats Yes No
7. Unexplained fatigue for more than three weeks Yes No

Patient Signature: _________________________________________________ Date: __________________

2042624 rev1023
For OMC use:
Tuberculin Skin Test (TST) (See documentation below.)
QuantiFERON® blood draw (See QuantiFERON® Results and Explanation)
Tuberculin Evaluation by Clinician Needed

Questions Reviewed by: ______________________________________________ Date: ______________________

TST Administered by: ________________________________________________


(Legibly Print Full Name and Title or Symbol)

Date: _________________ Time: ______________ AM PM  Right Forearm  Left Forearm


Tuberculin Vial Information: Lot #: ________________ Expiration Date: __________ Manufacturer:___________

Resulted by: __________________________________ Clinic Name: _________________________________


(Legibly Print Full Name and Title or Symbol) (If read at any location other than OMC)

Date: _________________ Time: ______________ AM PM  Right Forearm  Left Forearm


Result: _________ mm  Positive  Negative Comments: ___________________________________________
Patient Signature: __________________________________________ Date: ___________________________

If unable to return to OMC’s Rochester Southeast Clinic for TST reading, please fax to 507.292.7069.
Olmsted Medical Center, 210 Ninth Street SE, Rochester MN 55904; phone 507.292.7144
Translated Versions – Consent – Tuberculosis (TB) Screening
English – 2042624 Spanish – 2112625 Somali – 2112725

2042624 rev1023

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