Fill out the form below OR Download TB Test and TB Screening PDF Form to fill it out manually Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastDO YOU CURRENTLY HAVE ANY OF THE FOLLOWING THAT HAS LASTED THREE (3) WEEKS OR LONGER? LayoutUnexplained productive cough? *YesNoUnexplained appetite loss? *YesNoNight sweats? *YesNoChest pain? *YesNoBloody sputum? *YesNoUnexplained weight loss? *YesNoUnexplained fever? *YesNoShortness of breath? *YesNoIncreased fatigue? *YesNoHAVE YOU EVER? LayoutEver been told you have TB? *YesNoHad a positive TB skin test? *YesNoLived with anyone with TB? *YesNoHad a BCG vaccination? *YesNoPlease acknowledge and Initial *I acknowledge and certify that all answers provided on this form are true and accurate to the best of my knowledge.LayoutInitial Here *Date *Submit Form