Do you know your TB status?

Tuberculosis is curable and preventable. An estimated 58 million lives were saved through TB diagnosis and treatment between 2000 and 2018. Ending the TB epidemic by 2030 is among the health targets of the Sustainable Development Goals.

Kindly fill the form below about your TB status to help us process your application.

Share your results

Prefix

First Name *

Middle Name *

Last Name *

Email Address

Please select your Negative TB Skin Test (PPD) date

Please Select your Positive TB Skin test (PPD) Date

Please select the last date you carried out a chest Xray test

Have you ever had a complete course (of at least 9 months) of INH therapy? *YesNo

Kindly explain what transpired

Have you ever had Active, untreated Tuberculosis? *YesNo

Have you ever had Acquired Immunodeficiency syndrome (HIV)? *YesNo

Have you ever had severe or poorly treated Diabetes Mellitus? *YesNo

Have you ever had any disease associated with severe immunologic deficiency? *YesNo

Have you ever had Silicosis (Obstructive lung disease associated with inhalation of silica)? *YesNo

Have you ever had Gastrectomy (removal of part or all of the stomach)? *YesNo

Have you ever had Excessive alcohol intake? *YesNo

Section II

Please indicate if you are having any of the following problems for three to four weeks or longer:

Chronic cough *YesNo

Production of Sputum *YesNo

Blood-Streaked Sputum *YesNo

Unexplained Weight loss *YesNo

Fever *YesNo

Fatigue/Tiredness *YesNo

Night sweats *YesNo

Shortness of Breath *YesNo

Close exposure to a case of communicable pulmonary tuberculosis in the past year *YesNo

Disclaimer and Signature

I certify that my answers are true and correct to the best of my knowledge. If this application leads to an employment, I understand that false and misleading information may result in my release

I certify that the details entered are correct *YesNo

Date *

Please do not fill in this field.

+(952)-222-9884

fred@healthassociates.us

evans@healthassociates.us

5747 West Broadway Avenue,
Suite 212D Crystal,
Minnesota 55428

Do you know your TB status?

Share your results

+(952)-222-9884

fred@healthassociates.us

evans@healthassociates.us

5747 West Broadway Avenue, Suite 212D Crystal, Minnesota 55428

Do you know your TB status?

Share your results

5747 West Broadway Avenue,
Suite 212D Crystal,
Minnesota 55428