Wichita State University Student Health Services Tuberculosis Evaluation
TB Intake Form 1/2015
Family Name/Last
First Name(s)/Given Name(s)
Middle Name(s)
( )
Birth Date (MM/DD/YY)
Local Street address (ex: 4000 E. 17
St., #9 Wichita, KS 67208)
Phone Number
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)
American Indian
Pacific Islander
Hispanic or Latino
Black Alaskan Native
Race not otherwise specified
Not Hispanic or Latino
try of
Birth and
Born in USA
If no
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)
Have you:
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
ever had a BCG vaccine
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
child care facility
correctional facility
In the past year have you lived, worked, or volunteered in
long term care facility
health care facility
homeless shelter
mycobacteriology lab
rehabilitation center
Section C (Review of Symptoms) Are you having any of these symptoms right now:
Productive cough (lasting longer than 3 weeks); Date of onset ____/____/____
Blood in urine
Weight loss
Pain in the chest
Coughing up blood or sputum
Shortness of breath
Swollen lymph glands of the neck, axilla, groin, etc.
Night sweats
Fever (recurrent)
Fatigue (severe)
I co
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.
Patient’s Signature
Today’s Date