ANNUAL HEALTH SCREEN FORM
Patient Information
PLEASE COMPLETE ONLY ONE OF THE FOLLOWING ANSWERS

OR

PLEASE COMPLETE ONLY ONE OF THE FOLLOWING ANSWERS

OR


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:

Changes in Medical Condition (check all that apply)

5. TUBERCULOSIS SCREEN

Since your last Health Screen Questionnaire:

Have you had a positive reaction to PPD? If YES, did you or are you currently receiving prophylactic treatment?

Have you been diagnosed with Tuberculosis? If YES, were you treated?

Have you had a chest x-ray to test for Tuberculosis? If YES, was it positive?

6. TB Questionnaire

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

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