TB Questionnaire


Patients Name : Email:
Date of Birth: Today’s Date:
 
Tuberculosis (TB) is a disease caused by TB germs and is usually transmitted by an adult person with active TB lung disease. It is spread to another person by coughing or sneezing TB germs into the air. These germs may be breathed in by the child.

Adults who have active TB disease usually have many of the following symptoms: cough for more that two weeks duration, loss of appetite, weight loss of ten or more pounds over a short period of time, fever, chills and night sweats.

A person can have TB germs in his or her body but not have active TB disease (this is called latent TB infection or LTBI).

Tuberculosis is preventable and treatable. TB skin testing (often called the PPD or Mantoux test) is used to see if your child has been infected with TB germs. No vaccine is recommended for use in the United States to prevent tuberculosis. The skin test is not a vaccination against TB.

We need your help to find out if your child has been exposed to tuberculosis.
       
Place a mark in the appropriate box: Yes No Don't Know

       
TB can cause fever of long duration, unexplained weight loss, a bad cough (lasting over two weeks), or coughing up blood. As far as you know:

   
       
has your child been around anyone with any of these symptoms or problems? or
       
has your child had any of these symptoms or problems? or
       
has your child been around anyone sick with TB?
       

       
Was your child born in Mexico or any other country in Latin America, the Caribbean, Africa, Eastern Europe or Asia?
       
Has your child traveled in the past year to Mexico or any other country in Latin America, the Caribbean, Africa, Eastern Europe or Asia for longer than 3 weeks?
       
If so, specify which country/countries?      
       

       
To your knowledge, has your child spent time (longer than 3 weeks) with anyone who is/has been an intravenous (IV) drug user, HIV-infected, in jail or prison or recently came to the United States from another country?
       

 
Has your child been tested for TB? Yes if yes, specify date
    No
       
Has your child ever had a positive TB skin test? Yes if yes, specify date
    No
       
       
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Pediatric services are available to all children; office visit fees can be billed to medical insurance or paid in cash.
A sliding schedule of fees for uninsured children is available. Contact us now for more information.
The information contained in this website is to provide information of a general nature about the
practice and pediatric medical conditions. Neither Dr. Leonhardt nor Bee Well Pediatrics, P.A. is engaged in rendering medical
advice or recommendations. You should always consult your doctor for advice.