Read TB.Symp.Screen.English.2006.pdf text version

Division of Public Health, Prevention Services Branch Tuberculosis Program 404-657-2634 fax: 404-463-3460 http://health.state.ga.us/programs/tb

Tuberculosis (TB) Symptom Screen

Name: ________________________________________ M ____ F ____ Date of Birth: __________________________ Last skin test: _____________________________________________________________________________________

(Name, address, city, state, zip, and phone number of place where test was given)

Test Date: __________ Results _____ mm

Positive __ Negative __

Chest X-Ray: Normal ___ Abnormal ___

Were you treated for: Latent TB infection (LTBI)? Yes __ No ___ #Months ___ TB Disease? Yes __ No __ #Months ___ If yes, When? _________________ Where? _______________________________________________________________ Name of Medications: ________________________________________________________________________________

Today's Date _____________________________

Do you have a cough? If yes, how long have you had it? What color is the mucus? ________________ Do you have night sweats? Do you have fevers? Have you lost weight without trying? Have you been tired or weak? If yes, how long has it lasted? Do you have chest pain? If yes, how long has it lasted? Do you have shortness of breath? If yes, how long has it lasted? Do you know anyone who has these symptoms? Yes ______ # Days ______ # Days ______ # Days ______ # Days ______ Are you coughing up blood? Yes ______ # Weeks ______ Yes ______ Yes ______ Yes ______ No ______ Yes ______ # Weeks ______ Yes ______ # Weeks ______ Yes ______ # Weeks ______ Yes ______ No ______ # Months ______ No ______ No ______ No ______ # Pounds ______ No ______ # Months ______ No ______ # Months ______ No ______ # Months ______ No ______

Name _________________________ Address ____________________________________ Phone________________

Action Taken

(check all that apply) No sign of active TB at this time Chest X-ray not needed at this time Discussed signs and symptoms of TB with client Client knows to seek health care if symptoms of TB appear Further action needed · Isolated · Given surgical mask · Chest X-Ray is needed · Sputum samples are needed · Referred to Doctor / Clinic (Specify): · Other (Specify):

Signature of Person Making the Assessment _____________________________________________________________ Signature of Client ____________________________________________

DPH06/059W

Date ______________________________

Rev.03.2006

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