Appendix 3G: TB Screening Tool for Children and Younger Adolescents Name: _____________________________________ ART#: _______________________ Gender: M F Date of Birth: ___/___/___ Date of Screening: / / / / / / / / / / / / Age: Is child currently receiving anti-TB medications? (Yes or No) Yes Yes Yes Yes Yes Yes No No No No No No If Yes, STOP Screen. Rescreen after completion of TB Treatment. If No, answer questions below. Is child currently receiving Isoniazid Prophylactic Therapy (IPT)? Yes Yes Yes Yes Yes Yes No No No No No No (Yes or No) TB Exposure History: contact with a person diagnosed with Yes Yes Yes Yes Yes Yes No No No No No No pulmonary TB in the past 12 months? (Yes or No) TB Symptom Screen: Does the currently have any of the following TB symptoms? (Yes or No) Does child currently have cough? Yes Yes Yes Yes Yes Yes No No No No No No Does child have documented weight loss or failure to thrive during Yes Yes Yes Yes Yes Yes No No No No No No the past 3 months, not responding to nutritional rehabilitation? Does have fever? Yes Yes Yes Yes Yes Yes No No No No No No Screening Results: (A through C ) Positive Positive Positive Positive Positive Positive Positive = presence of one or more of symptoms Negative Negative Negative Negative Negative Negative Negative= absence of all symptoms Follow up: Child Has No Exposure to TB and TB Symptom Screen is / / / / / / / / / / / / Negative: Re-screen in 6 months. Write date for next screen. Child Has Exposure to TB and /or Positive Symptom Screen: CXR CXR CXR CXR CXR CXR Child is a TB Suspect and needs to be evaluated for TB disease. This □ □ □ □ □ □ AFB AFB Smear AFB Smear AFB Smear AFB AFB Smear includes physical exam, CXR, sputum for AFB, gastric aspirate, or □ □ □ □ □ □ Induced sputum Initial/Signature:
Appendix 3G: TB Screening Tool for Children and Younger Adolescents Name: _____________________________________ ART#: _______________________ Gender: M F Date of Birth: ___/___/___ Date of Screening: / / / / / / / / / / / / Age: Is child currently receiving anti-TB medications? (Yes or No) If Yes, STOP Screen. Rescreen after completion of TB Treatment. If No, answer questions below. Yes No Yes No Yes No Yes No Yes No Yes No Is child currently receiving Isoniazid Prophylactic Therapy (IPT)? (Yes or No) Yes No Yes No Yes No Yes No Yes No Yes No TB Exposure History: contact with a person diagnosed with pulmonary TB in the past 12 months? (Yes or No) Yes No Yes No Yes No Yes No Yes No Yes No TB Symptom Screen: Does the currently have any of the following TB symptoms? (Yes or No) Does child currently have cough? Yes No Yes No Yes No Yes No Yes No Yes No Does child have documented weight loss or failure to thrive during the past 3 months, not responding to nutritional rehabilitation? Yes No Yes No Yes No Yes No Yes No Yes No Does have fever? Yes No Yes No Yes No Yes No Yes No Yes No Screening Results: (A through C ) Positive = presence of one or more of symptoms Negative= absence of all symptoms Positive Negative Positive Negative Positive Negative Positive Negative Positive Negative Positive Negative Follow up: Child Has No Exposure to TB and TB Symptom Screen is Negative: Re-screen in 6 months. Write date for next screen. / / / / / / / / / / / / Child Has Exposure to TB and /or Positive Symptom Screen: Child is a TB Suspect and needs to be evaluated for TB disease. This includes physical exam, CXR, sputum for AFB, gastric aspirate, or Induced sputum □ CXR □ AFB □ CXR □ AFB Smear □ CXR □ AFB Smear □ CXR □ AFB Smear □ CXR □ AFB □ CXR □ AFB Smear Initial/Signature:
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