TB Screening - Pinecone Health LLC

Date form completed *//

Name (First Name and Last Name) *

Gender *

Select your Gender

Date of Birth *//

Phone Number *

Symptoms of active TB disease

Select Yes or No for the following

1. Coughing ( greater than 3 weeks) *

Yes
No

2. Production of Sputum *

Yes
No

3. Blood Streaked Sputum *

Yes
No

4. Chest pain *

Yes
No

5. Unexpected Weight Loss/Poor Appetite *

Yes
No

6. Fatigue /Tiredness *

Yes
No

7. Night sweats *

Yes
No

8. Coughing up blood *

Yes
No

9. Fever/chills *

Yes
No

10. Shortness of Breath *

Yes
No

TB History

Have you ever had a positive reaction to a TB skin test or TB blood test? *

Yes
No

If yes Date *//

Number of millimeters of induration in mm (copy) *

Number should be in mm

Have you had a TB skin test in the past 12 months? *

Yes
No

If yes Date *//

Number of millimeters of induration in mm *

Number should be in mm

Results *

Have you ever had the vaccine series for COVID-19? *

Yes
No

Have you ever had the BCG vaccine? *

Yes
No

Have you ever beeen treated for latent TB infection? *

Yes
No

Have you ever beeen treated for active TB disease? *

Yes
No

Have you ever had a severe adverse reaction to a TB skin test? *

Yes
No

Have you received Live-virus vaccine within the past 6 weeks? *

Yes
No

Signature of Pinecone *

Date *//

Signature of Applicant *

Date *//