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TB Questionnaire 3/6/2018 TB Risk Assessment . Several risk factors for TB that have been used to select patients for TB screening historically or in mandated programs are not included among the components of this risk assessment. TB symptoms can progress slowly and/or mimic other diseases. Tht is risk assessment does no supersede any mandated testing. It will only let us In the private healthcare sector a child should have a TB Risk Assessment performed at every well-child visit. 821 PURPOSE The purpose of this form is to document the current pulmonary history, the results of any previous TB skin tests and/or chest x-rays. It will not prevent TB. The Annual Tuberculosis Questionnaire is used to evaluate your current TB status. TB can be prevented and treated. A TB risk assessment has been completed for the individual named below. ADULT TUBERCULOSIS (TB) RISK ASSESSMENT QUESTIONNAIRE (To satisfy a Education Code Section 49406 and h and Safety e Sections 121525‐121555) CERTIFICATE OF N To be signed by the d health care provider ng the risk assessment and/or examination The TB Risk Assessment Form (TB 512) is a tool to assess and document a patient’s TB symptoms and/or risk factors. Baseline Individual TB Risk Assessment HCP should be considered at increased risk for TB if any of the following statements are marked “Yes”: Temporary or permanent residence of ≥1 month in a country with a high TB rate. Both Sections and signature are required to be completed in their entirety, regardless of your response in Section 1. The skin test is not a vaccination. This questionnaire targets TB Document G: State of Hawaii TB Risk Assessment for Adults and Children Hawaii State Department of Health Tuberculosis Control Program 1. Your answers to the questions below will let us know if your child might have been exposed to TB. INSTRUCTIONS Patient Identification Information- Complete demographic information. Yes No Documented history of previous NEGATIVE TB test in the past 12 months If YES, attach copy of test results If NO, refer for TB test Section III: Disposition Step 1 Cough lasting 3 or more weeks plus any other symptom Step 2 Evaluation for TB Infection (TBI) Step 3 Action Needed: Step 4 Action Taken: (Check only one) Documented Risk factors for TB have been identified; further testing is recommended to determine the presence or absence of tuberculosis in a communicable form. TB RISK ASSESSMENT INSTRUCTIONS For the following persons who are at highest risk of developing active tuberculosis disease if they are infected, tuberculin skin tests are considered positive at 5mm of induration or larger. Provider name (print) Patient name (print) Facility name Date of birth Street address (Place sticker here if applicable) Recent contacts of TB case patients Persons with fibrotic changes on chest radiograph consistent with prior TB Instructions Page for Pediatric TB Risk Assessment revised 10/2016 The Pediatric Tuberculosis (TB) Risk Assessment should be performed at first contact with a child, then at 6 months, 1 year of age and every year thereafter. This is However, certain populations may be mandated for testing by statute, regulation, or policy. INSTRUCTIONS: This TB Risk Assessment form is annual. You can develop symptoms a few weeks after contracting the bacteria – or not until years after initial infection. … Annual Tuberculosis Screening Questionnaire . Tuberculosis (TB) Risk Assessment Questionnaire for Students1 Prior to use of this form, the school nurse must review the student’s health record and assure that the student is compliant with the requirements for a current health examination (within past 2 years) and up-to-date immunizations. If your answers show your child might have picked up the TB germs, we will want to give him or her a tuberculin skin test (TST). Completing this form will also help in determining the need for further medical testing and evaluation. Directions for Completing the Form Print clearly and complete this form according to the instructions provided below. TUBERCULOSIS RISK ASSESSMENT AND QUESTIONNAIRE FORM No. Check for TB symptoms • If there are significant TB symptoms, then further testing (including a chest x-ray) is required for TB clearance. (Please print) Section 1: Do you have history of positive TB? ( print ) Patient name ( print ) Facility name Date of Street. 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