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:
• 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) ?
3. Have you been in contact with someone with known Tuberculosis disease of the lung (since last
TB risk assessment)?
4. Have you traveled outside of the US in the past year?
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
b. Coughing up blood
c. Unexplained fever for more than 3 weeks
d. Unexplained weight loss
e. Drenching night sweats
TB SCREENING AND TREATMENT HISTORY (since last TB risk assessment):
1. Have you been diagnosed with active or latent TB disease?
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: ______________________
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