Sunil N. Lalla, M.D. PA, Bharti Lalla, M.D. FAAP

First Name *

Last Name *

Date of Birth: *

Date of Completion: *

(1) Has the child ever had a positive TB skin test in the past ? *

(2) If the answer to the question above is yes, state when:

(3) Has any family member been diagnosed with Tuberculosis? *

(4) If the answer to the above is yes, Is this family member been treated with anti TB medications ? *

(5) Was the child born in the US ? *

(6) If no, which country was the child born in ?

(7) Has the child travelled outside the US in the past year ? *

(8) If so, which country and when

(9) How many people live in the Home? *

(10) Does the child or any family member suffer from cancer, immune deficiency, HIV or other immune compromising disorders? *

(11) If yes please elaborate

(12) Does any family member work in a nursing home or other facility with known risks for TB transmission? *

(13) What is the Educational level of the parents? *

Please Total the above numbers

Signature: *

Please print your name in the signature field

* Required field