TB Risk Questionnaire

TB Risk Questionnaire

Storybook Pediatrics TB Risk Questionnaire

(MM/DD/YYYY)
(MM/DD/YYYY)

Current Contact Information

Primary email with verification
Other email with verification
1. Has your child ever received BCG (a TB vaccine cometimes given in foreign countries)? *
2. Has there ever been TB, or a positive TB skin test, in any household member? *
3. Was your child born outside the United States? *
4. Has your child lived outside the United States for more than a month? *
5. Was any household member (like the list of people in question 2) born outside the United States? *
6. Does any household member have HIV or AIDS? *
7. Has any household member worked in or been put in jail or prison in the last 5 years? *
8. Has any household member ever lived in a homeless shelter? *
9. Is your child a foster child or adopted child? *
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