Name

Email

Sex
MF

Emergency Contact/Relationship

Contact

Diabetes
YesNo

Kidney Disease
YESNO

Heart Disease
YESNO

High Blood Pressure
YESNO

Arthritis
YesNo

Mental Illness
YESNO

Epilepsy/Convulsions
YesNo

Swelling in the Extremities
YesNo

Migraine headaches
YESNO

Fainting or Dizziness
YesNo

Back pain
YesNo

Pain during urination
YesNo

Change in bowel habits
YesNo

Increased thirst
YesNo

Persistent sores/lumps
YesNo

Infectious Diseases
YesNo

Cancer
YesNo

Any other physical disability
YesNo

Change in energy level
YesNo

Frequent cough
YesNo

Have you had close contact with someone who has had TB disease?
YesNo

Have you had close contact with someone who has been treated for Latent TB Infection?
YesNo

4) Have you had prior diagnosis of active TB or Latent TB Infection, or positive skin test or positive blood test for TB?
YesNo

If yes, have you been treated with medication for TB?
YesNo

OR, for a positive TB test?
YesNo

Persistent cough for 3+ weeks
YesNo

Coughing up blood
YesNo

Persistent shortness of breath
YesNo

Night sweats for no known reason
YesNo

Chest pain
YesNo

Unexplained weight loss
YesNo

Loss of appetite
YesNo

Hoarseness
YesNo

Unexplained fatigue for 3+ weeks
YesNo

Fever or chills for no known reason
YesNo

Do you smoke?
YesNo

Do you drink alcoholic beverages?
YesNo

If yes, how much?

Do you take depressants, stimulants, or narcotic drugs that alter your behavior?
YesNo

Do you take prescription medications?
YesNo

If yes, what are you allergic to?

Name of your physician:

Address

Date

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