Tuberculosis Exposure Risk Assessment 6224 NAVMED 8
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TUBERCULOSIS EXPOSURE RISK ASSESSMENT FOR THE PATIENT (Including those with previous positive tuberculin skin test)(Check the correct response) 1. Since your last Tuberculosis Exposure Risk Assessment, were you exposed to anyone known to have or suspected of having active tuberculosis (i.e., individuals with persistent cough, weight loss, night sweats, and/or fever)? 2. Since your last Tuberculosis Exposure Risk Assessment or Post-Deployment Health Assessment (DD Form 2796), did you have direct and prolonged contact with any individuals of the following groups: refugees or displaced persons; patients hospitalized with tuberculosis , prisoners, or homeless shelter populations? Yes No Yes No Don't Know 3a. Check any countries where you have traveled or deployed to since your last Tuberculosis Exposure Risk Assessment. Bangladesh Ethiopia Pakistan UR Tanzania Brazil India Philippines Viet Nam Burma Indonesia Russian Federation Zimbabwe Cambodia Kenya South Africa None China Mozambique Thailand DR Congo Nigeria Uganda If any of these listed countries are selected, answer question 3c. If "other" is checked, write in the name of the country or countries. Other 3b. Have you recently traveled to Afghanistan for any reason other than as part of a deployment requiring completion of a Post Deployment Health Assessment (PDHA)? Yes No 3c. During this travel, did you have prolonged direct contact with the local population? Prolonged direct contact is generally understood as having been within six feet of a person with a bad continuous cough for at least 8 consecutive hours on a single day, or for a total of at least 15 hours per week of a multi-week stay. Yes No 4a. Have you recently had a chronic cough lasting more than 2 weeks? Yes No 1. Questions 1 through 4 reviewed, all responses are negative, no further action is required. Yes No 2. There is at least one positive answer, patient to continue to medical officer for assessment. Yes No 4b. If you marked YES to chronic cough, did you have any of the following at the same time? Fever Cough up Blood Unexplained Weight Loss If Yes, go to 3c. Otherwise, go to 4a. Night Sweats If any are checked, see the medical officer for evaluation. FOR THE SCREENER FOR THE PROVIDER (Expand on above answers to document decision making in determining risk) (Note: Prior treated TST reactors require clinical evaluation to rule out active TB, not a repeat TST). 1. Provider Comments 2. Tuberculosis risk assessment, based on above responses (If the answer to one or more of questions 1, 2, 3c, or 4b is a YES, test the patient.) Minimal Risk Increased Risk 3. Recommend Latent Tuberculosis Infection (LTBI) Testing Yes No PROVIDER'S NAME PROVIDER'S SIGNATURE DATE PATIENT'S IDENTIFICATION: (For typed or written entries, give: Name - last, first, middle; SSN; Sex; Date of Birth; Rank/Grade.) HOSPITAL OR MEDICAL FACILITY STATUS DEPARTMENT / SERVICE SPONSOR'S NAME RELATIONSHIP TO SPONSOR NAVMED 6224/8 (Rev. 3-2011) RECORDS MAINTAINED AT SSN
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