Tb Questions 3 - 5 Years DOWNLOAD PDF Tb Questions 3 - 5 Years Name of ChildDate of BirthOrganization administering questionnaireDateEmail AddressTuberculosis (TB) is a disease caused by TB germs and is usually transmitted by an adult person with active TB lung disease. It is spread to another person by coughing or sneezing TB germs into the air. These germs may be breathed in by the child.Adults who have active TB usually have many of the following symptoms: cough for more than two weeks duration, loss of appetite, weight loss of ten or more pounds over a short period of time, fever, chills and night sweats. A person can have TB germs in his or her body but not have TB disease (this is called latent TB infection or LTBI). Tuberculosis is preventable and treatable. TB skin testing (often called the PPD or Mantoux test) or a TB blood test (called an IGRA) is used to see if your child has been infected with TB germs. No vaccine is recommended for use in the United States to prevent tuberculosis. The test is not a vaccination against TB.Place a mark in the appropriate box Yes No Don't Know TB can cause a fever of long duration, unexplained weight loss, a cough (lasting over two weeks), or coughing up blood. As far as you know has your child: been around anyone with any of these symptoms or problems? or had any of these symptoms or problems? or been around anyone sick with TB? YesNoDon't KnowWas your child born in: Mexico or any other country in Latin America, the Caribbean, Africa, Eastern Europe or Asia?YesNoDon't KnowHas your child traveled in the past year to: Mexico or any other country in Latin America, the Caribbean, Africa, Eastern Europe or Asia for longer than 3 weeks? If so, specify which country/countries:YesNoDon't KnowTo your knowledge, has your child spent time (longer than 3 weeks) with: anyone who is/has been an intravenous (IV) drug user, HIV-infected, in jail or prison or recently came to the United States from another country?YesNoDon't KnowHas your child been tested for TB? *YesNospecify dateHas your child ever had a positive TB skin test? *YesNospecify dateHas your child ever had a positive TB blood test? *YesNospecify dateFor school/healthcare provider use onlyPPD / IGRA administered (circle one)Date Administered:Date Read (if PPD):Result of PPD:Result of IGRA test:PositiveNegativeIndeterminate/InvalidType of service provider (i.e. school, Health Steps, other clinics):printed nameProvider phone number:CityCountyIf positive, referral to healthcare provider:YesNoIf yes, name/contact of provider:12-11494 TB Questionnaire for Children (Rev. 3/2020)Texas Department of State Health ServicesTuberculosis (TB) Questionnaire for Children12-11494 TB Questionnaire for Children (Rev. 3/2020)Submit form
