Fillable Positive Tuberculosis Screening Questionnaire (Springfield Technical Community College)

Fill Online, Printable, Fillable, Blank Positive Tuberculosis Screening Questionnaire (Springfield Technical Community College) Form

Use Fill to complete blank online SPRINGFIELD TECHNICAL COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Positive Tuberculosis Screening Questionnaire (Springfield Technical Community College)

On average this form takes 19 minutes to complete

The Positive Tuberculosis Screening Questionnaire (Springfield Technical Community College) form is 1 page long and contains:

  • 2 signatures
  • 25 check-boxes
  • 57 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Springfield Technical Community College

BROWSE SPRINGFIELD TECHNICAL COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Health and Wellness Center · Building 19, Room 177 · Phone (413) 755-4230 · Fax (413) 755-6045
Positive Tuberculosis Screening Questionnaire
Name:
Date:
(last)
(first)
(middle)
Address:
(Street address) (Apartment Number) (City)
(State) (Zip code)
Telephone:
Date of Birth:
Type of Evaluation:
Initial
Annual
Post Exposure
Date of First
Positive TB test:
Type of Test:
Degree of
reaction:
Unknown
(Mantoux, Tine)
(millimeters)
Have you ever received
BCG: (Tuberculosis
vaccine)?
No
Yes
Unknown
If yes, when,
where?
Have you ever had
an abnormal chest
x-ray?
No
Yes
Unknown
If Yes, when, where?
Have you ever been treated
with medicine for
Tuberculosis?
No
Yes
Unknown
If yes, did you
take all of the
medication?
No
Yes
Unknown
What type, dosage, duration?
Country of birth:
U.S.A.
Other__________
Date of
entry to
U.S.A.
Have you been in close contact
with anyone who was recently
diagnosed with Tuberculosis?
No
Yes
If yes, Who?
Extensive travel or living outside
the USA within past 5 years?
No
Yes
If yes, where?
Medical History:
Insulin-dependent Diabetic
Steroid Therapy
Cancer of head, neck, lung
Kidney disease
Silicosis
Leukemia, Lymphoma, or blood disorder
Stomach/intestinal surgery
Organ Transplant
Immunodeficiency or HIV disease
Do you have any of the following symptoms:
Chronic cough?
No
Yes
If yes,
frequency?
Productive
cough?
No
Yes
If yes,
color of sputum?
Persistent
night sweats?
No
Yes
If yes,
how often?
Chronic
fatigue?
No
Yes
If yes,
duration:
Loss of
appetite?
No
Yes
Involuntary
weight loss?
No
Yes
If yes,
how much?
Signature of patient:
(date)
Evaluator’s comments: (To be completed by STCC Health Services Department.)
Annual review
No
Yes
Chest x-ray
No
Yes
If yes,
date and result.
Referral for
further eval.
No
Yes
If yes,
describe.
Signature of evaluator:
(date)
click to sign
signature
click to edit
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Positive Tuberculosis Screening Questionnaire (Springfield Technical Community College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 26 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document