Fort Hays State University

STUDENTS:

TB Screening Form
FHSU Student Health Center

Name Date

Address

City SSN

Phone: Home Work

DOB | Male Female | If female, are you pregnant? Yes No

Ethnic Origin Hispanic Non-Hispanic

Height Weight LMP Contraception

Occupation: Student/Other

Country of Origin Arrival Date to US

Screening History

Have yu ever had a BCG Vaccine? Yes No - If yes, when?

Have you ever had a TB skin test? Yes No - If yes, when?
Positive mm induration | Negative mm induration

Have you ever had a chest x-ray? Yes No - If yes, when?
If yes, why? General Physical Positive TB Test
What was the result?

Received live vaccine iwthin the past six weeks for: Yellow Fever MMR Varicella

Allergies:

Current Meds:

Treatment/Disease History

Have you ever had Tuberculosis? Yes No

Have you ever taken medication for tuberculosis exposure, infection or disease?
Yes No - If yes, when?
Where?

What medications did you take?
Streptomycin Isoniazid (INH) Rifampin Pyrazinamide (PZA)
Ethambutol Other (list)

How long was treatment? Did you complete treatment? Yes No

If no, why not?

Text-Only Version - Site Map - Contact the Webmaster with any questions or comments concerning this Web site.