Annual TB Symptoms Review Name First Last Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SSN Date Form CompletedMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Medical History and Risk Factor Review:Most recent TB skin test:Year Reading (mm) Read as: Positive Negative Since your last TB skin test have you entered a TB isolation room or had exposure to a known case of TB? Yes No I Don’t Know If yes, please specify location: Time at location: Since your last TB skin test have you lived with or had close contact with someone who has TB disease? Yes No I Don’t Know Since your last TB skin test have you traveled and/or lived overseas? Yes No If yes, where? How long were you there? Since your last TB skin test have you worked in a prison or homeless shelter? Yes No Since your last TB skin test have you had an abnormal CXR? Yes No If yes, when? And what were the results? Since your last TB skin test have you been told by a health practitioner that your immune system is suppressed or compromised? (This may affect the results of your test) Yes No HIV infection and other medical conditions may cause a TB skin test to be negative even when TB infection is present.Sign and Symptom ReviewSince your last TB skin test have you experienced any of the following symptoms for more than three weeks at a time? (Please select yes or no)Excessive sweating at night Yes No Hoarseness Yes No Excessive weight loss Yes No Persistent coughing Yes No Coughing up blood Yes No Persistent fever Yes No Excessive fatigue Yes No Name First M.I. Last DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Agreement I guarantee the above is true to the best of my knowledge.
