Wichita State University Student Health Services Tuberculosis Evaluation
TB Intake Form 1/2015
First Name(s)/Given Name(s)
Local Street address (ex: 4000 E. 17
St., #9 Wichita, KS 67208)
Field of Study (i.e. nursing, education, PT etc.)____________________________________________
Every section must be completed. Please mark all that apply. If nothing applies, mark “None.”
Section A (Personal History)
Race not otherwise specified
t born in the USA, Country of Birth (specify) _____________________ Arrival Date in USA: ____________
Have you ever traveled outside the USA?
No Yes If yes, where? ________________________________ For how long? _____________________
Have you resided in another country for more than three months?
No Yes If yes, where? _________________________________When? ___________________________
Section B (Medical History and TB Risk Factors)
ever had a positive TB test
ever taken medication for tuberculosis date________how long_______
ever had a positive Quantiferon blood test
been in contact with a person who has active TB
had a viral infection (ex. chickenpox) in the last 30 days
ever had a chest x-ray due to a positive TB test
received immune globulin in the past three months
recently completed or are currently on corticosteroid or immunosuppressive therapy (like chemotherapy)
received a measles, mumps, rubella, yellow fever, varicella, or Flu-Mist vaccine in the last 30 days
In the past year have you lived, worked, or volunteered in
long term care facility
health care facility
Section C (Review of Symptoms) Are you having any of these symptoms right now:
Productive cough (lasting longer than 3 weeks); Date of onset ____/____/____
Coughing up blood or sputum
Swollen lymph glands of the neck, axilla, groin, etc.
nsent to this paper/electronic screening for TB. If SHS determines that I need further testing, I also consent to receiving TB testing and chest x-rays as
needed to screen for TB. I understand that if I am considered by SHS to be a high-risk student, I am not to attend any classes until my TB evaluation is complete.