This document contains forms for screening nursing professionals for tuberculosis (TB) and other diseases at ERA Lucknow Medical College and Hospital. It lists questions about TB symptoms, previous treatment, family history, and test results. It also screens for additional diseases like diabetes, high blood pressure, cancer, and respiratory illnesses. The final section is a consent form for an employee to agree to TB screening as part of their annual checkup since TB is a communicable disease prevalent in India.

1. ERA LUCKNOW MEDICAL COLLEGE AND HOSPITAL
BASIC DETAIL OF THE EMPLOYEE
SNO EMP ID EMPLOYEE NAME AGE/SEX D/O,S/O,W/O RESIDENCE/
MOBILE NO
OCCUPATION
SCREENING FOR TUBERCLUSIS TO ALL NURSING PROFESSIONAL :
SNO SCREENING OF TB YES NO REMARKS
1 Cough ( More than two days)
2 Fever
3 Weight loss
4 Appetite
5 Chest pain
6 Night sweating
7 Cough with blood
8 Previous treatment of TB is there or not?
9 Additional
10 Heredity of TB
11 Sputum test done/not done/if done than
reports of sputum test
12 X-Rays / Other test
13 Sign
14 Remarks
Remarks
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2. ADDITIONAL DISEASES SCREENING IF ANY: (YES/NO)
SNO ADDITIONAL DISEASES YES NO REMARKS
1 Diabetes
2 High Blood Pressure
3 Cardiac Disease
4 Cancer
5 Immuno-suppressive therapy
6 Palliative therapy
7 Kidney disease
8 Liver Disease
9 Respiratory Disease
10 Asthma
11 If any Known Disease
12 Any other disease
13 More than 60 age
14 Less than 10 years child
Remarks
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Consent for screening TB to nursing employee:
This is to inform that
.MR/MS/MRS………………………………..D/o,W/O,S/O………………………………………
working as nursing professional at ELMCH, era university. I willingly participate screening
program for TB as a my yearly check up and One way to Screen communicable diseases leading
In India is TB also. So Fully I cooperative to give needed information as per criteria for
screening process.
Signature of the Employee:
Date:
Screening done by :
Date:
Signature of the Verified Officer :
Date :