• Annual TB Symptoms Evaluation

    IntelyCare, Inc
  • In the last 2 years, have you had temporary or permanent residence of greater than or equal to 1 month in a country with high TB rates? Any Country other than the U.S, Canada, Australia, New Zealand, and those in Northern or Western Europe*
  • Do you have current or planned immunosuppression, including human immunodeficiency virus (HIV) infection, organ transplant recipient, treatment with a TNF-alpha antagonist (e.g., infliximab, etanercept, or other), chronic steroids (equivalent of prednisone ≥15 mg/day for ≥1 month) or other immunosuppressive medication*
  • Have you had close contact with someone who has had infectious TB disease since your last TB test*

  • Have you experienced any of the following symptoms in the past year?

  • A productive cough for more then 3 weeks*
  • Coughing up blood*
  • Unexplained weight loss*
  • Fever, chills, or night sweats for no known reason*
  • Persistent shortness of breath*
  • Unexplained fatigue*
  • Chest pain*
  • Date*
     - -

  • NOTUSED Hidden: Healthcare providers with a documented history of a positive TB skin test or who are unable to complete TB skin testing due to medical contraindications are required to complete an evaluation for symptoms of TB in lieu of an annual chest x-ray. Below is a list of symptoms frequently associated with TB disease.

    Please review the list and indicate any symptoms you may currently have, or have had, in the past 12 months by choosing a response to all questions.

  • NOTUSED HIDDEN: If responses are "No", no action to be taken, employee exhibits no symptoms of TB.

    If any of the above symptoms are present (Yes), the employee will be referred to a physician for further evaluation. The employee must submit documentation from the physician that they are free of tuberculin infection. A copy of this documetnation will be placed in their medical file.

     

  • NOTUSED Hidden: Night Sweats
  • NOTUSED Hidden: Recent travel out of country
  • Should be Empty: