Healthcare TB Survey Form

HEALTHCARE TB SURVEY FORM

Purpose: This form screens for tuberculosis (TB) risk factors, symptoms, prior testing and treatment to determine need for further diagnostic evaluation or treatment. Accurate completion is required for appropriate clinical decision-making. Information provided is confidential and will be used in accordance with applicable privacy rules.

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance & Coverage

Medical History

TB Screening Questions (Check all that apply)

Symptoms: Check each symptom the patient currently has

Respiratory / Constitutional Symptoms Persistent cough greater than 2 weeks
Coughing up blood or bloody sputum
Unexplained weight loss
Fever or chills
Night sweats

Risk factors: Check all that apply

HIV infection or other immunosuppression
Recent close contact with known active TB case
Previously treated for latent or active TB
Born or lived in country with high TB incidence
History of homelessness or residence in congregate settings

Prior TB Testing and Imaging

Date of most recent TB test:    Type of test:    Result:

If tuberculin skin test (TST), induration size (mm):

Chest X-ray: Date:    Findings:

Consent & Authorization

I acknowledge that I have been informed of the purpose of TB screening and that additional diagnostic testing (including blood tests, skin testing, chest radiograph, and microbiologic studies) may be recommended based on screening results. I understand that a positive screening result does not confirm active disease and that further evaluation is required.

I consent to TB testing and evaluation as recommended by the treating clinician.
I decline TB testing at this time.

I authorize release of TB screening and test results to public health authorities when required by law and to other healthcare providers for continuity of care. This authorization is voluntary and will expire on:

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the facility's privacy practices regarding protected health information and understand how my TB screening and testing information will be used for treatment, payment and public health purposes as permitted or required by law.

I acknowledge receipt of privacy practices.

Clinical Assessment (For Provider Use)

Tests Ordered:

Recommended Disposition:
Start treatment for latent TB infection
Refer for further evaluation for possible active TB
No further TB-specific action indicated at this time

Clinician Name:    License/ID:

Clinician Signature:    Date:

Certification

By signing below, I certify that the information I have provided is true and complete to the best of my knowledge. I understand that withholding or providing false information may adversely affect clinical decision-making and public health actions. I authorize the release of relevant medical information as described above.

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