<p> Annual TB Symptom Assessment Sheet To Be Completed by your Primary Health Care Provider</p><p>Name: DOB: Date: </p><p>Address: </p><p>Telephone Number: </p><p>Program: Banner ID #: </p><p>FOR HISTORY OF POSITIVE PPD: </p><p>Date of last TB Symptom Assessment: </p><p>Date of Positive PPD: </p><p>Any symptoms of TB since last TB assessment? Yes No </p><p>Any high risk history since last TB assessment? Yes No </p><p>Any known exposures to infectious TB? Yes No </p><p>If yes explain </p><p>TB SYMPTOM ASSESSMENT:</p><p>Cough? Hemoptysis? Night Sweats? </p><p>Weight Loss? Sputum production? Fever/Chills? </p><p>Chest Pain? Unexplained Fatigue? Pregnant? </p><p>Diabetes? Kidney Disease? Hepatitis? </p><p>COPD/Asthma? Immunosuppressed? BCG? </p><p>Birth Country? </p><p>Past Treatment for TB? </p><p>Last CXR? Referral? </p><p>Health Care Provider signature or stamp </p><p>Return form to: 400 East Ave, Room 1240 Warwick, RI 02886 or fax to (401) 825-1077</p>