Pediatric TB Risk Assessment Questionnatre Pediatric TB Risk Assessment Questionnatre Date* MM slash DD slash YYYY Student/PatientLast Name*First Name*Middle Name*Gender* Male Female I hereby give consent for a school nurse or District Administrator to communicate with my child's initial Califomia Physician or Califomia Licensed Health Care Provider.QuestionsYes NoWas your child born in a high risk region? Has your child ever traveled to a high risk country for more than 1 week? Has a family member or contact had tuberculosis disease? Has a family member or close contact had a positive Tuberculin skin test? Has a familv member had a positive TST or IGM result? Has your child spent time (more than 3 weeks) with anyone who has been in jail (or prison), homeless shelter, uses illegal drugs. or has HIV? Does your child drink law milk or eat unpasteurized cheese? Does your child have a household member who was born in an area that is high risk for tuberculosis? if thre is "yes" response to any of the question above ,then TST or IGRA testing should be performed. Has your child ever been tested for TB? Yes(if yes,specify date) No MM slash DD slash YYYY Has your child ever had a positive TB skin test? Yes(if yes,specify date) No MM slash DD slash YYYY Note: if the child being screened was previously tested, had a documented negative TST or IGRA result, and has not acquired any new tisk factor since the last assesment,then he/she does not need to be retested. *High Risk Region = Any country in Aferica,Asia,Central America,or Eastern Europe. Parent or Legal Guardian SignatureTo be completed by Phsician or Licenesed Health Care Provider Student/Patient:is not a risk tuberculosis infection.SignatureDate MM slash DD slash YYYY Califormia Physician or Califormia Licensed Health Care Provider(printrd name)AddressPhone NumberFax NumberMedical Office Information Stamp
