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<< Healthcare Wide Hazards - Tuberculosis

Healthcare Wide Hazards
Early Detection of Tuberculosis

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. Reviewing the individual's TB history
  2. Assessing current symptoms

INSTRUCTIONS:

  • Circle each answer given by patient.
  • Add your comments as the evaluator at the bottom of the page.
  • Institute the facility's exposure control measures outlined in the facility's Exposure Control Plan, Respiratory Protection and Medical Surveillance Program and refer the individual for further evaluation if the individual has:

(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.

TB HISTORY (Part 1)

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

Evaluator's Signature:______________________________
Date:_____________


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