This document contains a form for screening employees for tuberculosis (TB) at Era Lucknow Medical College and Hospital. The form collects information about an employee's name, address, age, sex, occupation and screens for symptoms of TB like cough, fever, weight loss, appetite changes, chest pain, night sweats, coughing up blood and history of previous TB treatment. It also screens for additional risk factors like diabetes, high blood pressure, cardiac disease, cancer, immunosuppressive therapy and collects information on sputum tests, x-rays or other tests done and notes any additional remarks.

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