Student and Employee Health

Main Content

Pulmonary History Form

* - Required Fields

First Name*
Last Name*
Are you an employee or a student?*  
Employee ID*
Job Title*
Student ID*
Date of Birth*
Email Address*
Please check one*
1. Do you have a history of:
1a. A cough lasting for 3 weeks or more?*
If yes, is your cough productive or non-productive?
1b. Coughing up blood?*
1c. Fever?*
1d. Fatigue?*
1e. Difficulty breathing?*
1f. Night sweats?*
1g. Unintended weight loss?*
If yes, how many pounds? How many months?*
2. Do you smoke?*
3. Have you ever tested positive for HIV?*
4. Have you been around anyone who has TB?*
5. When was your TB test first positive?
5a. What medication did you receive and for how long?
5b. Have you ever had a TB (IGRA) blood test?
If yes, when?
Results
5c. Have you received Bacillus Calmette-Guerin (BCG)?
6. What was the date of your last chest x-ray?*
7. What were the results?*
Signature*