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Tuberculosis Risk Assessment

Tuberculosis Risk Assessment

Name
DOB
History of temporary or permanent residence (for􀀐 1 month) in a country with a high TB rate (i.e., any country other than Australia, Canada, New Zealand, the USA, and those in western or northern Europe)
Current or planned immunosuppression, including HIV infection, receipt of an organ transplant, treatment with an TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone 􀀐 15 mg/day for 􀀐 1 month) or other immunosuppressive medication
Close contact with someone who has had TB disease
Treatment for latent TB infection
Prior diagnosis of active TB or latent TB infection or a positive skin test or positive blood test for TB
Treatment with medication for TB or for a positive TB test
Productive cough for more than 3 weeks
Coughing up blood
Unexplained Weight Loss
Fever, chills, or drenching night sweats for no known reason
Persistent shortness of breath
Unexplained fatigue for more than 3 weeks
Chest pain
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