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Tuberculosis Risk Assessment for Adults (16 Years Old) Hawaii State Department of Health Tuberculosis Control Program Name: Yes No 1. Can you read English? 2. Were you born outside the United States?
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How to fill out tuberculosis risk assessment for
How to fill out tuberculosis risk assessment form:
01
Begin by providing personal information such as name, date of birth, and contact details.
02
Determine if you've ever been diagnosed with tuberculosis by selecting the appropriate option (Yes/No) and providing relevant details if necessary.
03
Indicate if you've been in close contact with anyone diagnosed with tuberculosis within the last six months.
04
Specify any symptoms you may have experienced, such as cough, weight loss, fever, or night sweats.
05
Fill in your medical history, including any respiratory conditions or previous tuberculosis treatments.
06
Mention any recent travel to countries with a high prevalence of tuberculosis.
07
Provide information on your current living conditions, such as crowded settings or poor ventilation.
08
Fill out the occupational history section, mentioning if you work in healthcare, detention facilities, or homeless shelters.
09
Discuss any previous tuberculosis testing or vaccinations.
10
Lastly, sign and date the form, acknowledging that the information provided is true and accurate.
Who needs tuberculosis risk assessment form:
01
Individuals working in healthcare settings, especially those with direct contact with patients.
02
People residing in crowded or confined environments where tuberculosis transmission is more likely, including correctional facilities, homeless shelters, and nursing homes.
03
Those who have been in close contact with someone diagnosed with tuberculosis, as they may have an increased risk of infection.
04
Individuals with symptoms suggestive of tuberculosis, such as persistent cough, weight loss, or fever.
05
People planning to travel to countries with a high prevalence of tuberculosis should also consider completing a risk assessment form.
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