TB Risk Assessment

TB Risk Assessment

Complete this form to help assess your risk for tuberculosis (TB).

Your responses will assist healthcare providers in evaluating your potential risk and determining if further testing is recommended.

First Name(Required)

Last Name(Required)

Have you ever been diagnosed with TB before?

Yes

Have you ever lived with or been in close contact with someone who has TB?

Yes

Not Sure

Have you traveled to or lived in a country with a high rate of TB in the past 5 years?*

Yes

Email(Required)

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