Fillable TB SCREENING FORM (Loma Linda University)

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TB SCREENING FORM (Loma Linda University)

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TB SCREENING FORM
Name: ___________________________________ Student ID#:________________________ Date: _____________
School: __________________________________ Birth date: _____/_____/_____ Phone: _____________________
MM DD YYYY
Please indicate if you have any of the following symptoms:
Yes No
__ __ Chronic cough
__ __ Production of sputum – if yes, what color sputum: _________________
__ __ Blood-streaked sputum
__ __ Unexplained weight loss
__ __ Unexplained fatigue/tiredness
__ __ Night sweats
__ __ Fever
Updated 4/19/2016
PATIENT IDENTIFICATION
Name:
Birth Date:
Medical Record #:
Student Health Service
24785 Stewart St. Evans Hall, Ste. 111
Loma Linda, CA 92354
Phone: (909) 558-8770
Fax: (909-558-0433
TB Screening Form
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Completed 22 August 2020

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