Regional Sites:

Chesterfield Royal Hospital Tel No: 01246 512188 Email: crhft.occhealth@nhs.net

Derbyshire Community Health Services Tel No: 01246 515696 Email:
dchst.occupationalhealth@nhs.net University Hospital of Derby and Burton Trust: Email:
uhdb.occhealth@nhs.net
Derby Site Tel No: 01332 788331 Burton Site Tel No: 01283 593166

TUBERCULOSIS SYMPTOM QUESTIONNAIRE

Please complete the following and return to Occupational Health.
First Name: Princess Floraine Surname: Amata DoB: March 25, 1990

Address: 40B, Manor Park Court, Northmead Drive, Uttoxeter New Road, Derby
Post Code: DE22 3QH

Job Title: Staff Nurse Area of Work/Ward: Division of Surgery, ICU

Contact No/Mobile: +639458458516 Work email address

GP Name & Phone No:

Please complete the following questions: YES NO

Have you lived in the UK for less than 1 year or returning from a prolonged stay ✔
abroad of over 3 months?

If yes, please state which countries and for how long.

Have you had a chest x-ray within the last 1 Year? ✔

If yes, please state why and was the x-ray result normal?
For visa purposes, Normal chest x ray.

Have you ever had tuberculosis (TB)? ✔

Have you had close contact with TB – (patients / specimens), please state when? ✔
This would include contact with a family member with tuberculosis.

Have you had any changes to your health status in the last year – i.e.: ✔
immunosuppression or immunosuppressant treatment?

Have you had any of the following symptoms?

A persistent dry or productive cough that lasts more than 3 weeks ✔

Unexplained weight loss ✔

Night Sweats ✔

Unexplained fever ✔

Tiredness and fatigue ✔

Loss of appetite ✔
 Enlarged lymph glands – groin/neck/axilla ✔

Other information/comments

Signed: Date:

March 13, 2022

Occupational Health & Wellbeing

Regional Sites:
Chesterfield Royal Hospital Tel No: 01246 512188 Email: crhft.occhealth@nhs.net
Derbyshire Community Health Services Tel No: 01246 515696 Email:
dchst.occupationalhealth@nhs.net University Hospital of Derby and Burton Trust: Email:
uhdb.occhealth@nhs.net
Derby Site Tel No: 01332 788331 Burton Site Tel No: 01283 593166