Tuberculosis (TB) Management Form

1. Todays Date *

2. First Name *

3. Last Name *

4. Date of Birth *

5. Email *

6. I am a known positive TB responder? *
NO   YES  

Immunosuppression: This includes HIV infection, organ transplant, treatment with a Tumor Necrosis Factor (TNF) - alpha antagonist (infliximab, etanercept, etc.), chronic steroids (equivalent or more than prednisone 15 mg per day for 1 month), or other immunosuppressive medication.


7B. Do you have current or planned immunosuppression? *
YES   NO  

8. Have you had close contact with someone who was diagnosed with infectious Tuberculosis (TB) in the past 12 months? *
YES   No  

9. Within the last three months, have you had a prolonged, productive cough (3 weeks or longer)? *
YES   NO  

10. Within the last three months, have you been coughing up bloody or discolored sputum?
YES   NO  

11. Within the last three months, have you had unexplained fever/chills? *
YES   NO  

12. Within the last three months, have you had unexplained chest pain? *
YES   NO  

13. Within the last three months, have you had unexplained night sweats? *
YES   NO  

14. Within the last three months, have you had unexplained fatigue or weakness? *
YES   NO  

15. Within the last three months, have you had unexplained weight loss? *
YES   NO  

16. Within the last three months, have you had a loss of appetite? *
YES   NO  

17. Have you ever received a BCG vaccine? *
YES   NO  

18. Have you ever had a positive TB test? *
YES   NO  

19. If you answered yes to question #18, what type of TB testing did you have? *
TB Skin Test   Blood Testing (QFT or T-spot)   Unsure of test done   Select if you answered "No" to question #18.  

20. If you answered yes to question #18, have you had a chest x-ray within the past 2 years?
YES   NO   Select if you answered "No" to question #18  

21. If you answered yes to question #18, did you receive treatment after the positive TB test? *
YES   NO   Select if you answered "No" to question #18.  

22. If you answered yes to question #18, have you had prolonged/productive cough, bloody or discolored sputum, fever/chills, unexplained chest pain, night sweats, unexplained fatigue/weakness, or unexplained weight loss or loss of appetite in the past 12 months? *
YES   NO   Select if you answered  

23. By typing my FULL NAME - I certify that the information on this form is correct and complete to the best of my knowledge. *