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DACC Nursing Program Student Handbook 2012-2013APPENDIX – LDOÑA ANA COMMUNITY COLLEGE NURSING PROGRAMAnnual TB Health Questionnaire FormAll students/employees with positive TB skin tests must complete and sign this questionnaire annually. Thequestions relate to signs and symptoms of Tuberculosis. Please check "yes" or "no" to each symptom. If youcheck "yes" to any item, in the comment section below, describe the symptom, including when it started.Should you have questions, please contact the Nursing Program Secretary at (575) 527-7735.1. Fatigue2. Loss of Appetite3. Unexplained Weight Loss4. Low Grade Fever5. Coughing Up Blood6. Night SweatsSYMPTOM YES NO7. Cough Lasting More Than Three (3) Weeks8. Cough Combined with Fever, Chills, Sweating, and Weakness(Not Responsive to Treatment)9. Shortness of Breath10. Dull Aching or Tightness in ChestCOMMENTS:___________________Signature___________________Name (Printed or Typed)__________________Date62 | P a g e