Student Health & Wellness Name ________________________ University of Iowa 4189 Westlawn Address ________________________ Iowa City, IA 52242 ________________________ University ID _________________________ Tuberculosis (TB) Screening and Testing Questionnaire CIRCLE ANSWERS 1. How old are you? ____________________________ 2. Have you ever had a vaccine to prevent tuberculosis (BCG vaccine)? NO YES UNKNOWN (Usually given as infant or child. You may have scar on your arm from the vaccine) 3. Have you ever had a positive/reactive TB skin test? NO YES; date: 4. Have you ever had a positive/reactive TB IGRA blood test? NO YES; date: 5. Have you ever been told you have TB? NO YES; date: 6. Have you ever been treated for either active or latent TB? NO YES; date: 7. Have you ever had a chest X-ray which showed tuberculosis? NO YES; date: 8. Do you have any chronic illnesses (for example: diabetes, asthma, ulcerative NO YES colitis, Crohn's disease, rheumatoid arthritis, lupus, leukemia, lymphoma, chronic renal failure)? Please circle the illnesses 9. Have you ever been diagnosed with or treated for cancer? NO YES 10. Have you ever been diagnosed with AIDS, tested positive for HIV, used illegal NO YES injectable drugs, or shared needles with anyone? 11. Do you take any medications that make your immune system weak such as NO YES TNF-alpha blocker (Enbrel, Remicade) or steroids (prednisone >15 mg per day for > 1 month)? List the medications here: 12. Were you born or have you lived in a country that has a high incidence of NO YES active tuberculosis disease? (see list provided) Please write the country name(s): 13. What countries have you traveled to in the last 2 years? Please write the NO YES country name(s) 14. Have you ever lived with someone known or suspected to have active TB? NO YES 15. Have you received any of these live vaccinations in the past 4 weeks? NO YES Flumist , MMR, oral Typhoid, Varicella (Chicken Pox), Yellow fever (Circle the vaccines) 16. Do you have allergies to latex, medications, or any vaccine? List the NO YES allergies here: 17. Have you ever lost your balance or fainted from having blood drawn? NO YES CONTINUED ON OTHER SIDE OF THIS PAGE Tuberculosis (TB) Screening and Testing Questionnaire Page 2 18. Do you have any of the following symptoms that are sometimes symptoms of tuberculosis: o Chest pain NO YES o Cough that has lasted for 3 weeks or longer? NO YES o Coughing up blood NO YES o Fever NO YES o Loss of appetite NO YES o Night sweats NO YES o Unexplained weight loss NO YES Student Signature ________________________________________ Date______________________ Telephone number: _____________________________ Email address: _________________________ (Please print legibly) Staff Printed Name: STAFF USE ONLY International student Health science student Employment requirement Status post international travel Date: Other ____________________ T-spot QFT-G TST placed on _____________ @ ___________ Manufacturer Lot number Legal Name__________________________________________________ Place label here: University ID #_______________________________________________ Birth Date: Day______/Month______/Year______ Address_____________________________________________________ S:\Forms\Medical Record\TB Screening and Testing Questionnaire.doc 5-14 List of Countries Divided by “High” and “Low” TB Incidence Rates Afghanistan Central African Georgia Malawi Paraguay Sudan Algeria Republic Ghana Malaysia Peru Suriname Angola Chad Guatemala Maldives Philippines Swaziland Argentina China Guinea Mali Poland Tajikistan Armenia Colombia Guinea-Bissau Marshall Islands Portugal Thailand Azerbaijan Comoros Guyana Mauritania Qatar Timor-Leste Bahrain Congo Haiti Mauritius Republic of Korea Togo Bangladesh Côte d’Ivoire Honduras Mexico Republic of Trinidad and Belarus Democratic India Micronesia Moldova Tobago Belize People’s Indonesia (Federated States Romania Tunisia Benin Republic of Iran (Islamic of) Russian Federation Turkey Bhutan Korea Republic of) Mongolia Rwanda Turkmenistan Bolivia Democratic Iraq Morocco Saint Vincent and Tuvalu (Plurinational Republic of the Kazakhstan Mozambique the Grenadines Uganda State of) Congo Kenya Myanmar Sao Tome and Ukraine Bosnia and Djibouti Kiribati Namibia Principe United Republic of Herzegovina Dominican Kuwait Nauru Senegal Tanzania Botswana Republic Kyrgyzstan Nepal Serbia Uruguay Brazil Ecuador Lao People’s Nicaragua Seychelles Uzbekistan Brunei Darussalam El Salvador Democratic Niger Sierra Leone Vanuatu Bulgaria Equatorial Guinea Republic Nigeria Singapore Venezuela Burkina Faso Eritrea Latvia Niue Solomon Islands (Bolivarian Burundi Estonia Lesotho Pakistan Somalia Republic of) Cabo Verde Ethiopia Liberia Palau South Africa Viet Nam Cambodia Fiji Libya Panama South Sudan Yemen Cameroon Gabon Lithuania Papua new Guinea Sri Lanka Zambia Gambia Madagascar Zimbabwe “Low Incidence” Areas (TB incidence rates < 20 cases/100,000 population in 2012) Albania Cook Islands Germany Lebanon Norway Spain Andorra Costa Rica Greece Luxembourg Oman Sweden Antigua and Croatia Grenada Macedonia, Samoa Switzerland Barbuda Cuba Hungary Yugoslav Saint Kitts and Syrian Arab Australia Cyprus Iceland Republic of Nevis Republic Austria Czech Republic Ireland Malta Saint Lucia Tonga Bahamas Denmark Israel Monaco Samoa United Arab Barbados Dominica Italy Montenegro San Marino Emirates Belgium Egypt Jamaica Netherlands Saudi Arabia United Kingdom Canada Finland Japan New Zealand Slovakia United States Chile France Jordan Slovenia Source: World Health Organization Global Health Observatory, Tuberculosis Incidence 2012. For future updates, refer to http://apps.who.int/ghodata. .