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STUDENT HEALTH SERVICES ? WELLNESS CENTER 715 North Avenue ? New Rochelle, NY 10801 Phone: (914) 633-2548 ? Fax: (914) 712-4102 DOB: Student s Name: ID #: Tuberculosis (TB) Screening Questionnaire
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How to fill out tb screening form 1
How to fill out TB Screening Form 1:
01
Begin by obtaining a copy of TB Screening Form 1 from the appropriate healthcare provider or organization.
02
Read through the form carefully to familiarize yourself with the information it requires.
03
Start by providing your personal details, such as your full name, date of birth, address, and contact information. Make sure to ensure the accuracy of these details.
04
Continue by providing your medical history, including any previous TB diagnoses, treatment, or exposure to TB.
05
Answer the questions related to symptoms, such as if you have experienced persistent coughing, weight loss, night sweats, or fatigue.
06
If applicable, provide information about any recent travel to countries with a high incidence of TB.
07
Make sure to answer all questions accurately and honestly, as this information is crucial for an accurate assessment.
08
Once you have completed filling out the form, review it carefully to ensure all information is provided correctly.
09
Sign and date the form, affirming that the information you have provided is true and accurate to the best of your knowledge.
10
Return the completed TB Screening Form 1 to the authorized healthcare provider or organization as instructed.
Who needs TB Screening Form 1:
01
Individuals who have been identified as potentially at risk for tuberculosis (TB) may be required to fill out TB Screening Form 1.
02
This may include individuals who have had close contact with someone diagnosed with TB or individuals with symptoms suggestive of TB, such as prolonged cough.
03
Healthcare workers, particularly those who frequently come into contact with infectious diseases, may also be required to complete this form to ensure the safety of both patients and themselves.
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What is tb screening form 1?
TB screening form 1 is a document used to screen individuals for tuberculosis.
Who is required to file tb screening form 1?
Individuals working in high-risk environments or healthcare settings are required to file TB screening form 1.
How to fill out tb screening form 1?
TB screening form 1 can be filled out by providing personal information, medical history, and undergoing a tuberculosis test.
What is the purpose of tb screening form 1?
The purpose of TB screening form 1 is to identify individuals who may have tuberculosis and to prevent the spread of the disease in high-risk settings.
What information must be reported on tb screening form 1?
Information such as personal details, medical history, and tuberculosis test results must be reported on TB screening form 1.
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