ROYAL ADELAIDE HOSPITAL
Thoracic Medicine

SA TB Services

STUDENT QUESTIONNAIRE

Please complete the following questionnaire if you are a Health Care student
studying in SOUTH AUSTRALIA.

This is a one time requirement prior to FIRST placement, valid for five years.

DO NOT COMPLETE THIS QUESTIONNAIRE MORE THAN ONCE!

The information you submit will be used only for the purpose of assessing
your need for further TB screening.
Once you fully complete and submit the questionnaire,
you will be sent a follow-up email from SA TB Services within two weeks.
All personal information will be held confidentially and securely by SA TB Services
and will not be shared with any third parties.
If you do not wish to complete this form online,
please ring the Chest Clinic, 275 North Tce, Adelaide on 8222 5307

Surname

Given Name
Date of Birth
Male  Female
Email

re-enter Email
Address Local (SA)

Suburb

Postcode
Home Telephone
Mobile
Local Doctor
Ethnicity
Aboriginal   Asian   African   Caucasian   Other  
Country of Birth

Date of Arrival
Visa/residency status
Permanent Resident   Temporary Resident   Australian Citizen  
Visa Type
Work   Student  
Institution/University, currently enrolled
Future employer/placement institution
Leave blank if unknown.

Course/Placement position

Commencement
Have you ever been in close contact with someone who has TB?
Yes  No
Have you ever had tuberculosis in the past?
Yes  No
If Yes, When?

Were you treated?
Yes  No
Have you been screened in Australia for TB in the past 5 years?
Yes  No
Do you have any of the following symptons?
Cough Yes  Duration (weeks):
   
No
Fever Yes  Duration (days/weeks):
   
No
Weight loss Yes  Amount (kgs):
   
No
Have you worked or lived outside of Australia for periods of more than 3 months?
Yes   No
Country Year left Length of stay
Have you ever been involved in the care of patients with TB?
Yes   No
If yes, please give details:
Have you ever worked in any of the following work units?
  If yes, state last year worked.  
Respiratory Unit Yes      No
Bronchoscopy Suite Yes      No
Laboratory (manipulation of specimens) Yes      No
Mortuary (manipulation of specimens) Yes      No
Have you had any vaccinations in the last 4 weeks?
Yes   No
If yes, please list:
Have you any of the following medical conditions?
Yes   No
Diabetes    Chronic renal disease    HIV Infection   
Chronic lung disease    Cancer    Autoimmune   
Are you currently taking any:
Yes   No
Steroids   Other immune-suppressants   Chemotherapy
If yes, please give details:
Do you have any allergies?
Yes   No
If yes, please give details:
Have you had a BCG tuberculosis vaccination?
Yes   No

Questionnaire submission will take some time,
please wait until the confirmation screen comes up,
and do not press the Submit button again.

http://www.pages.on.net/questionnaire.php
was last modified: May 22 2018 13:03:50.
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