British Medical Examination Registration Form

1. Has the applicant (or their child) had any of the following symptoms in the last three months: Cough， Fever，Haemoptysis，Night sweats，Weight loss

YES NO

• 2. ●Is there any history of previous TB?

  YES NO

• ●Has anyone in the household been diagnosed with TB in the last 2 years?

  YES NO

• ●Is there any history of recent contact with a case of active pulmonary TB (shared the same enclosed air space or household or other enclosed environment for a prolonged period for days or weeks)?

  YES NO

3. Have you ever had thoracic surgery, including heart, lungs, breasts, spine and chest wall, neck or upper belly surgery?

YES NO

5. For children only:
Is there any history of the following; any chronic respiratory disease, such as cystic fibrosis, previously thoracic surgery ,cyanosis, respiratory insufficiency that limits activity.

YES NO