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CHILDREN FIRST PEDIATRICS ROCKVILLE, MD SILVER SPRING, MD TB PREVENTIVE SCREEN QUESTIONNAIRE (STARTING AT 6 MONTHS.DONE YEARLY) Please fill in Yes or No to each question Patient Name: DOB: Date completed:
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How to Fill Out TB Preventive Screen Questionnaire:

01
Start by carefully reading the instructions provided with the TB preventive screen questionnaire. Make sure you understand the purpose of the questionnaire and the information required.
02
Fill in your personal details accurately, including your full name, date of birth, contact information, and any other requested identification information.
03
Answer the questions on the questionnaire honestly and to the best of your knowledge. Provide information about your medical history, including any past TB exposure or treatment, any current symptoms you may be experiencing, and any previous positive TB tests.
04
If there are any specific instructions or additional sections in the questionnaire, make sure to complete them as instructed. This may involve providing information about your recent travel history or contact with individuals known to have TB.
05
Double-check your answers to ensure accuracy and completeness. Review the questionnaire for any missing or incomplete responses before submitting it.
06
If you have any doubts or questions while filling out the questionnaire, consult with a healthcare professional for guidance and clarification.

Who Needs TB Preventive Screen Questionnaire?

01
Individuals who have recently been in close contact with someone diagnosed with active tuberculosis (TB) may need to fill out a TB preventive screen questionnaire. This helps assess their risk of developing TB.
02
People who have previously tested positive for latent TB infection (LTBI) or who have received treatment for TB may also need to complete a TB preventive screen questionnaire to monitor their health and determine the need for ongoing preventive treatment.
03
Healthcare workers, individuals in correctional facilities, and those living in communal settings like nursing homes or homeless shelters may be required to fill out a TB preventive screen questionnaire as part of routine screening protocols.
04
Immigrants and refugees from countries with a high prevalence of TB may also be asked to complete a TB preventive screen questionnaire as part of the immigration or asylum process.
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It is a questionnaire designed to assess the risk of contracting tuberculosis and to identify individuals who may require further testing or treatment.
Individuals who are at risk of contracting tuberculosis or who have been exposed to someone with tuberculosis may be required to fill out the questionnaire.
The questionnaire can be filled out online or in person, with questions about your medical history, symptoms, and potential exposure to tuberculosis.
The purpose is to identify individuals who may be at risk of tuberculosis and to provide early detection and treatment to prevent the spread of the disease.
Information such as medical history, symptoms, and potential exposure to tuberculosis must be reported on the questionnaire.
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