Annual TB Questionnaire

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number *

Country of Birth *

1. Have you traveled outside the U.S. since your last risk assessment? *

Yes
No

If yes, list countries and purpose of travel

2. Have you been diagnosed with a chronic condition that may impair your immune system? *

Yes
No

If yes, check all that apply

Chronic steroid use
Gastrectomy/intestinal bypass
Diabetes mellitus
HIV infection
Crohn’s disease
Dialysis/renal failure
Cancer of the head or neck
Rheumatoid arthritis
Chronic malabsorption syndromes
Silicosis
Use of TNA-a antagonist
Low body weight (10% or more below ideal)
Leukemia, lymphoma or Hodgkin’s disease

Other

3. Have you ever resided, worked or volunteered in any of the following facilities? *

Yes
No

If yes, check all that apply

Prison
Hospital
Nursing home
Homeless shelter
Other long term treatment center

4. Do you currently have any of the following symptoms? *

Yes
No

If yes, check all that apply

Cough greater than 3 weeks
Unexplained fever
Chest pain
Chills
Productive cough (coughing up something)
Night sweats
Respiratory difficulty (shortness of breath)
Loss of appetite
Coughing up blood
Unexplained weight loss
Fatigue
Weakness

5. Have you ever had contact with a person known to have active tuberculosis? *

Yes
No

6. Have you ever had an abnormal chest x-ray? *

Yes
No

7. Have you had a tuberculin skin test or IGRA before? *

Yes
No

If yes, list where the test was given as well as the date. If you had the test done through Craft Heath and don't recall the date you can indicate "On file with Craft Health."

a. If the test result was positive, did you take medications?

Yes
No

b. If you took medication(s), what did you take? Please provide name of medication or enter don't know if you don't recall.

c. Where were you treated? (City, state, country, doctor's contact information)

d.. In what year did you start treatment?

e. How long did you take this medication?

The information above is true and complete to the best of my knowledge, and I am aware that deliberate misrepresentation may jeopardize my health. I understand this information is confidential and will not be released without my knowledge and written permission. I understand that by typing my name below and clicking on "Submit," I am electronically signing this document. *

Date *

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