Tuberculosis Screening Questionnaire for Students
Student Information
Full Name
Date of Birth
Student ID
Symptom Review (past month)
Persistent cough (2+ weeks)
Yes
No
Fever
Yes
No
Night sweats
Yes
No
Unexplained weight loss
Yes
No
Coughing up blood
Yes
No
Risk Factors
Have you ever lived with or been in close contact with someone with active TB?
Yes
No
Have you ever had a positive TB skin test or blood test?
Yes
No
Country of birth
Has it been less than 5 years since arrival to this country?
Yes
No
Past Medical History
Have you previously been diagnosed or treated for TB?
Yes
No
Are you currently taking any immunosuppressive medications?
Yes
No
Other relevant medical history
Additional Comments