CCRI Student Health Services

Annual TB Symptom Assessment Sheet To Be Completed by your Primary Health Care Provider

Name: DOB: Date:

Address:

Telephone Number:

Program: Banner ID #:

FOR HISTORY OF POSITIVE PPD:

Date of last TB Symptom Assessment:

Date of Positive PPD:

Any symptoms of TB since last TB assessment? Yes No

Any high risk history since last TB assessment? Yes No

Any known exposures to infectious TB? Yes No

If yes explain

TB SYMPTOM ASSESSMENT:

Cough? Hemoptysis? Night Sweats?

Weight Loss? Sputum production? Fever/Chills?

Chest Pain? Unexplained Fatigue? Pregnant?

Diabetes? Kidney Disease? Hepatitis?

COPD/Asthma? Immunosuppressed? BCG?

Birth Country?

Past Treatment for TB?

Last CXR? Referral?

Health Care Provider signature or stamp

Return form to: 400 East Ave, Room 1240 Warwick, RI 02886 or fax to (401) 825-1077