About this template
This Tuberculosis (TB) Screening Form template is designed for healthcare professionals, clinics, and medical practices to efficiently evaluate patients for TB risk factors, symptoms, and exposure history. Whether preparing for employment clearance, clinical placement, or routine health evaluations, this form provides a structured way to collect vital medical history.
The template covers critical screening indicators, including persistent cough, unexplained weight loss, night sweats, known exposure to active TB cases, and relevant medical conditions or medications that impact immune status. By gathering this data digitally before an appointment, clinics streamline patient intake, reduce administrative friction, and maintain clear medical documentation.
Built for seamless use via Doc2Form, this template can be instantly converted into a ready-to-use Google Form. Share the link with patients via email, embed it on your practice website, or have individuals complete it on a tablet in your waiting room. All responses are securely organized in your Google Drive and connected Google Sheets, giving your clinical team instant access to patient health disclosures.
Key features
- Collect complete tuberculosis symptom and exposure histories online.
- Streamline patient intake before clinical visits.
- Organize all screening submissions automatically in Google Sheets.
- Fully customizable to match your clinic's specific screening protocols.
- Accessible on any device for quick patient completion.
Use cases
- Pre-employment medical clearances for healthcare workers and teachers.
- Routine annual health screenings in clinical practices.
- Student health evaluations for nursing and medical programs.
- Volunteer onboarding for hospitals and care facilities.
What this form collects
- Patient Full Name (Short answer)Enter your first and last name.
- Date of Birth (Date)Enter your date of birth (MM/DD/YYYY).
- Today's Date (Date)Select today's date.
- Healthcare Professional Name (Short answer)If applicable, enter the name of the clinician reviewing this screening.
- Reason for TB Screening (Dropdown)Select the primary reason for completing this screening today.
- TB Symptom Status (Checkboxes)Have you experienced any of the following symptoms lasting longer than 3 weeks? Select all that apply.
- TB Exposure Status (Multiple choice)To your knowledge, have you recently been exposed to someone with active tuberculosis?
- Medical Condition Status (Multiple choice)Do you have any medical conditions or take medications that weaken the immune system (e.g., HIV, immunosuppressive therapy, organ transplant)?
- Medical Condition Details (Paragraph)If you answered yes above, please provide details regarding your medical conditions.
- Medication Status (Multiple choice)Are you currently taking any prescription medications on a regular basis?
- Medication Details (Paragraph)If yes, please list the names and dosages of your current medications.
- Patient Acknowledgment and Signature (Short answer)By typing your full name below, you certify that the information provided in this screening form is accurate and complete to the best of your knowledge.
FAQ
How do I share this TB screening form with my patients?
Once Doc2Form generates your Google Form, you can share it via a direct link, email it to patients ahead of their visit, or embed it securely on your healthcare practice website.
Where are patient responses stored?
All submissions are saved directly to your Google Drive and linked Google Sheets, allowing your medical team to review responses in real-time.
Can I add custom screening questions specific to my clinic?
Yes. Because the template converts directly into a Google Form, you can easily add, edit, or reorder any questions using the standard Google Forms editor.
Is this form template free to use?
Yes, Doc2Form provides this template free of charge, allowing you to instantly create your Google Form without hidden fees.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.