Pediatric TB Risk Assessment Form

Name:

Date of Birth:

Date:

US Born?

Yes No

If no, Us Date of Arrival

Country of Birth:

1. Does the child have any symptoms of TB (cough, fever, night sweats, loss of appetite, weight loss or fatigue) or an abnormal chest X-ray?

Yes No

If yes, name of symptoms:

2. In the last 2 years, has the child lived with or spent time with someone who has been sick with TB?

Yes No

3. Was the child born in Africa, Asia, Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, The Caribbean or the Middle East?

Yes No

If yes, in what country was the child born:

4. Has the child lived or traveled in Africa, Asia, Pacific Islands (except Japan), Central America, South America, Mexico, Eastern Europe, The Caribbean or the Middle East for more than one month?

Yes No

If yes, in what country did the child travel to:

5.Have any members of the child’s household come to the United States from another country?

Yes No

If yes, name of country:

6. Is the child exposed to a person who:

Yes No

I currently in jail or who has been in jail in the past 5 years?
Has HIV?
Is Homeless?
Lives in a group home?
Uses illegal drugs?
Is a migrant farm worker?

If yes, name the risk factors the child is exposed to:

7. Is the child/teen in jail or ever been in jail?

Yes No

If yes, name of jail:

8. Does the child have any history of immunosuppressive disease or take medications that might cause immunosuppression?

Yes No

If yes, name of disease or medications:

If yes, to any of the above, the child has an increased risk of TB infection and should have a TB Skin Test/IGRA.

Adapted from IDPH Pediatric TB risk assessment form.

Your information will be encrypted.