This questionnaire gives guidance in identifying individuals with suspected or
confirmed TB so that appropriate controls can be promptly initiated.
The questionnaire has two parts:
(1) A persistent cough lasting 3 or more weeks and two or more symptoms of active TB.
(2) Had a positive TB test on mucous that he/she coughed up.
(3) Been told that he/she had TB and was treated, but never finished the medication.
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? |
|
Yes |
No
|
|
|
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 |
|
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Evaluator's Signature:______________________________ |
Date:_____________ |