Clover Health Services

History of positive TB test or TB disease

Yes

If yes, a symptom review and chest x-ray (if none performed in previous 6 months) should be performed at initial hire.

If there is “Yes” response to any of the questions below, then a tuberculin skin test should be performed.

1. One or more signs and symptoms of TB (Prolonged cough, weight loss, excessive fatigue)

Yes

2. Close contact with someone with infectious TB disease

Yes

3. Are you coughing more than 3 weeks

Yes

Have you recently coughed up blood?

Yes

Have you lost more than 5lbs in the last two months?

Yes

Had frequent fevers in the last month?

Yes

Had unusual sweating especially at night?

Yes

4. Have you ever had a TB Skin Test (TST)?

Yes

What was the result

Positive

Negative

Do you have proof of your TST?

Yes

If you marked “Yes” to any of the above questions, are you currently being seen by a physician?

Yes