Rev. 02/05/2021
Baptist Health South Florida
Visiting Learner Tb Symptoms & Risk Assessment
This form is not required for clinical rotation, but may be used in lieu of other Tb assessments during
approved time periods. If you have any questions, please contact the Baptist Health Office of
Academic Affairs at 786-467-2633.
MEDICAL RISK ASSESSMENT (Check box for each condition):
1. Do you have any of the medical conditions listed below:
Yes No
• Diabetes
• Cancer
• Kidney Failure
• Chronic Tobacco Use
• Immunosuppresive and / or Autoimmune
Diseases (i.e.: HIV, Crohns Disease or
Ulcerative Colitis, Rheumatoid Arthritis,
Psoriatic Arthritis, Lupus, etc.)?
2. Are you taking any immunosuppressive medications (Prednisone, methotrexate, cyclosporine,
Chemo therapy for cancer, medications for autoimmune diseases or inflammatory bowel disease,
such as, anti-TNFα or other biologic agents) ?
Yes No
3. Have you been in contact with someone with known Tuberculosis disease of the lung (since last
TB risk assessment)?
Yes No
4. Have you traveled outside of the US in the past year?
Yes No
4a. If yes, please indicate which country or countries you traveled to
outside the U.S.: __________________________
TUBERCULOSIS SYMPTOM REVIEW:
Do you currently have any of the following symptoms?
a. Productive cough for more than 3 weeks
Yes No
b. Coughing up blood
Yes No
c. Unexplained fever for more than 3 weeks
Yes No
d. Unexplained weight loss
Yes No
e. Drenching night sweats
Yes No
TB SCREENING AND TREATMENT HISTORY (since last TB risk assessment):
1. Have you been diagnosed with active or latent TB disease?
Yes No
1a. If yes, did you receive any treatment? Yes No
I attest that the information above is accurate to the bet of my knowledge, and have read the
attached documentation on Tb Elimination.
Learner’s Signature: ______________________
Date: ______________________
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