ACCS TB Questionnaire
American Critical Care Services
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Email *
First Name *
Last Name *
This questionnaire may apply to you because you have had a positive/sensitive PPD and are no longer required to have an annual PPD or annual chest x-ray. The following is to be completed annually and maintained in your personnel file.

Please read and put a check mark in the correct Yes/No space if you are experiencing any of the following symptoms or if any of the following apply to you:
1. Unplanned loss of weight (>10% of body weight) *
2. Night sweats *
3. Fever lasting several weeks *
4. Frequent coughing in the absence of a cold or flu *
5. Coughing blood-streaked sputum *
6. Unusual tiredness or weakness lasting weeks *
7. Pain in chest when taking a breath *
8. Have you been recently diagnosed with diabetes, silicosis, HIV disease, renal disease or liver disease? *
9. Have you recently been exposed to a family member or others with active TB? *
If you checked YES to any of the above questions, are you currently treating with a physician?
If YES to any of the above questions, please explain:
Note: If you develop ANY of the symptoms listed above, please contact your physician and American Critical Care Services immediately. A chest x-ray MUST be performed prior to working again. *
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