Adult Tuberculosis Risk Assessment • Use this tool to identify asymptomatic adults for latent TB infection (LTBI) testing. • Re-testing should only be done in persons who previously tested negative, and have new risk factors since the last assessment. • For TB symptoms or abnormal chest x-ray consistent with active TB disease-> Evaluate for active TB disease. Evaluate for active TB disease with a chest x-ray, symptom screen, and if indicated, sputum AFB smears, cultures and nucleic acid amplification testing. A negative tuberculin skin test or interferon gamma release assay does not rule out active TB disease. TB Assessment See the TB Risk Assessment User Guide at the BOTTOM of the page for more information about using this tool. Birth, travel, or residence in a country with an elevated TB rate for at least one month. • Includes any country other than the United States, Canada, Australia, New Zealand, or a country in western or Northern Europe. • If resources require prioritization within this group, prioritize patients with at least one medical risk for progression (see User Guide for list). • Interferon Gamma Release Assay is preferred over Tuberculin Skin Test for foreign-born persons. Immunosuppression, current or planned HIV infection, organ transplant recipient, treated with TNF-alpha antagonist (e.g., infliximab, etanercept, others), steroids (equivalent of prednisone ≥15 mg/day for ≥1 month) or other immunosuppressive medication Close contact to someone with infectious TB disease at any time. LTBI testing is recommended if any of the 3 boxes above are checked. If LTBI test result is positive and active TB disease is ruled out, LTBI treatment is recommended. Prioritize Persons with Risks for Progression If health system resources do not allow for testing of all persons who are born, traveled, or live lived in a country with an elevated TB rate for at least one month, prioritize patients with at least one of the following medical risks for progression: Check all that apply or Skip. Diabetes Mellitus Smoker within past 1 year End Stage Renal Disease Leukemia or Lymphoma Silicosis Cancer of Head or Neck Intestinal Bypass/Gastrectomy Chronic Malabsorption Body Mass Index (BMI) ≤20 History of chest x-ray findings suggestive of previous or inactive TB (no prior treatment). Includes fibrosis or non-calcified nodules, but does not include solitary calcified nodule or isolated pleural thickening. In addition to LTBI testing, evaluate for active TB disease. Full Name * Date of Birth * Assessment Date * Submit Adult Tuberculosis Risk Assessment User Guide