New Jersey Department of Health

Symptom Assessment for Pulmonary Tuberculosis (TB)

Name (Last, First, MI)

Birthdate (mm/dd/yyyy)

Street Address

Telephone Number

City

State

Zip Code

Date of Symptom Assessment (mm/dd/yyyy)

TB-Like Symptoms (Check all that apply):

Productive Cough of Undiagnosed Cause (more than 3 weeks in duration)

Coughing Up Blood (Hemoptysis)

Unexplained Weight Loss (10 pounds or greater without dieting)

Night Sweats (regardless of room temperature)

Unexplained Loss of Appetite

Very Easily Tired (Fatigability)

Fever

Chills

Chest Pain

If any symptoms are reported a chest radiograph and medical evaluation is needed.
No TB-Like Symptoms Reported or Observed
Name of Licensed MD/RN (Print)

Signature of Licensed MD/RN	Date

TB-5

OCT 13

TB-5, Symptom Assessmen for Pulmonary Tuberculosis (TB)

TB-5, Symptom Assessment, Pulmonary Tuberculosis, TB Services, TB

ewhite

2013-10-04

NJDOH