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TB Screening Form Template

Effortlessly Assess Tuberculosis Risk and Eligibility

If your clinic struggles to streamline tuberculosis screenings, our TB Screening Form Template is just what you need. Designed for healthcare professionals, this template helps you efficiently assess a patient's risk and eligibility for the TB vaccine. With features that ensure data accuracy, eliminate the need for coding, and enhance patient engagement, you can improve your workflow, save time during consultations, and ensure accurate documentation. Experience the ease of using this user-friendly template today-explore now!

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Full legal name
Date of birth
Email address
Phone number
City or town of residence
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Cough lasting 2 weeks or longer
Yes
No
Coughing up blood
Yes
No
Unexplained weight loss
Yes
No
Night sweats
Yes
No
Fever or chills
Yes
No
Chest pain or shortness of breath
Yes
No
In the past 2 years, have you had close contact with someone diagnosed with active TB disease
Yes
No
In the past 2 years, have you lived in or traveled for more than 1 month in a country with high TB rates
Yes
No
Settings you have lived or worked in for 1 month or more in the past 2 years (select all that apply)
Healthcare setting
Correctional facility
Homeless shelter
Long-term care facility
Laboratory handling TB specimens
None of the above
Prefer not to say
Health conditions or treatments that may weaken your immune system (select all that apply)
Are you currently pregnant
Yes
No
Not applicable
Prefer not to say
Have you ever had a positive TB test
Yes, TST (skin test) positive
Yes, IGRA (blood test) positive
No
Unsure
Date of your most recent TB test (if known)
Have you ever been diagnosed with active TB disease
Yes
No
If you were ever treated for TB, did you complete the full course
Completed treatment
Did not complete treatment
Not applicable
Unsure
Have you received the BCG vaccine
Yes
No
Unsure
Does your household include children under 5 years old
Yes
No
Prefer not to say
Occupation or role
Current housing situation
Stable housing
Temporary housing
Homeless/unsheltered
Prefer not to say
Preferred contact method for follow-up
Phone call
Text message
Email
Any of the above
Best time to contact you
Morning
Afternoon
Evening
Any time
Do you consent to be contacted about your TB screening and next steps
Yes
No
Signer full name
Signature date
I confirm the information provided is accurate to the best of my knowledge
Strongly disagree
Disagree
Neither agree nor disagree
Agree
Strongly agree
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Paper art illustration showcasing a TB screening form template for FormCreatorAI article

When to use this form

Use this template to screen patients, employees, or students before work, school entry, or volunteer service. It fits onboarding for hospitals, long-term care, childcare, shelters, and lab settings. You capture prior TB tests, chest X-ray history, exposure, travel, and current symptoms in minutes. If you run pre-placement exams, pair it with the Medical physical exam form to keep records in one file. For general health intakes or annual updates, add it alongside the Medical questionnaire form. The outcome: you know who needs a skin test or IGRA now, who needs a chest X-ray, and who can be cleared. That saves time, reduces repeat testing, and creates a clear paper trail for audits.

Must Ask TB Screening Questions

  1. Have you ever had a positive TB skin test (PPD) or blood test (IGRA)?

    This identifies prior infection and prevents unnecessary repeat testing. A yes answer helps you move straight to chest X-ray review and documentation.

  2. Have you had close contact with someone diagnosed with active tuberculosis in the past year?

    Recent close contact is a strong risk factor and triggers same-day testing and follow-up. It also helps you prioritize who needs precautions or rapid referral.

  3. Do you currently have symptoms such as a cough over 3 weeks, fever, night sweats, or unexplained weight loss?

    These red-flag symptoms suggest active disease and prompt urgent evaluation. Capturing them upfront improves safety for staff and other clients.

  4. Have you ever received treatment for TB or had an abnormal chest X-ray?

    Past treatment or imaging results change how you interpret new tests and whether further workup is needed. Record details or attach reports using the Medical chart review form to keep everything traceable.

  5. Do you have conditions or take medicines that weaken your immune system (for example, HIV, transplant, chemotherapy, or high-dose steroids)?

    Immune-suppressing factors raise the risk of progression, so you may need testing sooner and closer monitoring. If the role also requires respirator use, align your screening with the OSHA Respirator medical evaluation questionnaire form.

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