CCRI Student Health Services

TB SYMPTOM ASSESSMENT: Cough? Hemoptysis? Night Sweats? Weight Loss? Sputum production? Fever/Chills? Chest Pain? Unexplained Fatigue? Pregnant? Diabetes? Kidney Disease? Hepatitis? COPD/Asthma? Immunosuppressed? BCG? Birth Country? Past Treatment for TB? Last CXR? Referral? Health Care Provider signature or stamp. Return form to: 400 East Ave ... ................
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