Step 1: Tuberculosis Questionnaire

Please complete Step 1, below, before continuing on to the Tuberculosis Skin Test Consent form.

First Name*

Last Name*

Address*

City*

Phone*

Email Address*

Birthday*

Month Day Year

MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember Day01020304050607080910111213141516171819202122232425262728293031 Year20202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Gender

MaleFemaleOther

Purpose for TB Screening (please tick one)*

Education

Daycare

Medically Indicated

Admission to rehab/treatment centre

Residents under 65 years of age being admitted to Long-Term Care

Employment

Volunteer

Enter the code displayed*