ANNUAL HEALTH SCREEN FORM

Patient Information

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PLEASE COMPLETE ONLY ONE OF THE FOLLOWING ANSWERS (*)


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If you indicate that you have any of the below conditions, or if you answered YES to any of the below
statements, please explain below:

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TUBERCULOSIS SCREEN


Since your last Health Screen Questionnaire:

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TB Questionnaire


 (check any symptoms that you have had within the last year):

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I certify that I have answered these questions honestly to the best of my knowledge.

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