Please answer the following questionsFirst Name* Last Name* Phone Date of Birth MM slash DD slash YYYY Social Security Number General InformationPlease 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 Comments
