how to formulate the TB screening format for people

1. ERA LUCKNOW MEDICAL COLLEGE AND HOSPITAL
BASIC DETAIL OF THE EMPLOYEE
SNO EMP
ID
EMPLOYEE NAME D/O,S/O,W/O RESIDENCE/
MOBILE NO
AGE/SEX OCCUPATION
SCREENING FOR TUBER CLOSIS
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
Additional Diseases: Diabetes / High Blood Pressure /Cardiac Disease/Cancer/Immunosuppressive
therapy/Palliative therapy / Kidney disease/Liver Disease/Respiratory Disease/Asthma/Additional
Disease/Any other disease/More then 60 age/less then 10 years child