* = Required Information
First Name
*
Last Name
*
Phone
Date of Birth
Social Security Number
General Information
Please indicate if you are having any of the following for three to four weeks, or longer:
1. Unplanned weight loss (> 10% of body weight)
Yes
No
2. Night sweats
Yes
No
3. Chronic cough in absence of cold or flu (greater than 3 weeks)
Yes
No
4. Coughing blood-streaked sputum
Yes
No
5. Fever lasting several weeks
Yes
No
6. Unusual tiredness and weakness lasting weeks
Yes
No
7. Pain in chest when taking a breath
Yes
No
8. Have you been recently exposed to someone with TB?
Yes
No
9. Have you recently been diagnosed with diabetes, silicosis, HIV, renal disease, or liver disease?
Yes
No
10. Have you ever tested positive on a PPD test?
Yes
No
If you marked "Yes" to any of the above questions, are you currently being seen by a physician?
NA
Yes
No
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