Priority Pediatrics PC

Tuberculosis (TB) Exposure Risk Questionnaire to complete for Dr. T

Please register on my Updox Portal BEFORE starting this questionnaire, if you have not already previously registered, so that your work can be saved and completed in more than one seating if needed. Once you are registered on the Portal, you will be able to retrieve past sent forms and resend if needed. Also do NOT use your BACK Button or REFRESH, or you will lose all your Form information and need to start over. When completed, click SEND and the form will come securely to me. Thank you. Dr. T

Skin testing for Tuberculosis (TB) is no longer routine in the U.S. for the general population but is only recommended for selected high-risk of exposure groups. Please complete this form to help us determine if anyone in your family falls into a significant high-risk group that should have a TB skin test under current guidelines.

Name of Patient * Date of Questionnaire Completion * Name of Person(s) Completing Questionnaire * Has your child or an immediate family member been exposed to or in close contact with anyone with TB or at risk for TB? * Does your child have close contact with a person who has had a positive TB skin test result? * Has anyone in your immediate family ever had an organ transplant? * Does your child have a household member who was born outside of the United States (Asia, Africa, Latin America, Middle East)? * If Yes, what country? Has the child traveled (had contact with resident populations) to a high-risk country as listed above for more than 1 week? * If Yes, what country & WHEN? Does your child have a household member who has EVER traveled outside the United States (Asia, Africa, Latin America, Middle East)? * If Yes, what country & WHEN? Does your child spend time with anyone who has been in jail or a shelter, uses illegal drugs, or has HIV? * Has anyone in your immediate family household EVER been in jail, prison, or a nursing home. * Has anyone in your immediate family EVER worked in a laboratory that worked with TB specimens. *

Does your child or any HOUSEHOLD member have any of the following medical conditions which might affect the immune system?

Diabetes * Chronic kidney failure with dialysis * Leukemia * Lymphoma * Cancer of the head, neck or lung * Stomach surgery * Immune problems (for example, diagnosed with HIV disease or taken Prednisone or other swallowed steroid for longer than one month) * Has anyone in your immediate household family ever been told that he/she/you have an abnormal chest Xray? * Please elaborate if answered YES:

Has ANYONE in your immediate family household had any of the following symptoms RECENTLY?

Cough &/or hoarseness lasting more than 3-4 weeks * Recent unexplained weight loss * Fever or night sweats for more than a week * A cough productive of mucus/phlegm or coughed up blood * Please elaborate if any of the above answered YES:

If you answered NO to all of these questions, you (and your immediate family members) do NOT fall into one of the groups that should receive a TB skin test. This determination is based on current medical guidelines.

If you answered YES to any of these questions, you should talk with the doctor about the possibility of further health evaluation for members of your family.

Thank you for completing this questionnaire and forwarding it to the doctor.