Southwest Virginia Community College Nursing Program
Tuberculosis Symptom Screening Questionnaire
Printed Name: _______________________________Student ID #: ______________ Date: ___________
Symptoms of Active Tuberculosis (TB) Disease (student must check present or not present):
Coughing that lasts 3 weeks or longer
present not present
Pain in the chest
present not present
Sweating at night
present not present
Weakness & fatigue
present not present
Weight loss/no appetite
present not present
Coughing up blood or sputum
(phlegm from deep inside the lungs)
present not present
History (student must check yes or no; comment as needed)
Have you ever had an adverse reaction to a TB skin
Were you born outside of the US?
Have you traveled or lived outside of the US in the past
two years?
Have you ever had a positive reaction to a TB skin test?
Have you ever had a TB blood test? (test by drawing
blood in the lab)
Have you ever had the BCG vaccine? (not widely used in
the US but administered in other countries where TB is
Have you ever been treated for latent TB infection
Have you ever been treated for active TB disease?
Have you had household exposure to TB?
Student Signature: __________________________________________
This Tuberculosis Symptom Screening Questionnaire must be submitted annually while continuously
enrolled in the nursing program.
If submitting this questionnaire due to having a previously documented positive TB screening test or a
documented diagnosis of TB or Latent TB Infection (LTBI), it must be signed below by the healthcare
provider (MD, NP or PA) asserting that a symptom review was performed.
Healthcare Provider: Printed Name: _______________________________________________________
Signature: ____________________________________________________ Date: ___________________