HSIP - TB Symptom Survey:

Student ID: *
Last Name:
First Name:
School/Program:
In the past year, have you had any of the following symptoms?

1:Cough lasting longer than 3 weeks? Yes No
2:Fever? Yes No
3:Night sweats? Yes No
4:Unexplained weight loss? Yes No
5:Malaise/fatigue (unrelated to being a student)? Yes No
6:Bloody sputum? Yes No
7:Chest pain? Yes No
Please explain any YES answers: