TB Risk Screening-Parent Questionnaire

Pediatric Tuberculosis (TB) Risk Screening – Parent Questionnaire

Patient Name:

Date of Birth:

Please answer the following questions about your child. Select Yes or No.

Birth, travel, or residence in a country with an elevated TB rate for at least 1 month (includes any country other than the United States, Canada, Australia, New Zealand, or countries in western or northern Europe).

Yes No

Immunosuppression, current or planned. (e.g., HIV infection, organ transplant, treatment with immunosuppressive medications such as steroids or biologic medications)

Yes No

Close contact with someone with infectious tuberculosis (TB) disease at any time.

Yes No

Parent/Guardian Name:

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature:

Date:

Your information will be encrypted.