Latent Tuberculosis Screening Questionnaire

Last Updated: 13/05/2022

Personal Details

What is your full name *

What is your Date of birth *

What is your telephone number *

What is your address *

Screening Questions

If you were born in, or have spent more than 6 months over the past 5 years in one of the high risk of TB countries listed below you may be eligible:

Afghanistan, Angola, Bangladesh, Benin, Bhutan, Botswana, Burkina Faso, Burundi, Cote d’Ivoire, Cabo Verde, Cambodia, Cameroon, Central African Republic, Chad, Comoros, Congo, DRP Korea, DR Congo, Djibouti, Eritrea, Equatorial Guinea, Ethiopia, Gabon, Gambia, Ghana, Greenland, Guinea, Guinea Bissau, Haiti, India, Indonesia, Kenya, Kiribati, Laos DR, Lesotho, Liberia, Madagascar, Malawi, Mali, Marshall Islands, Mauritania, Mauritius, Micronesia, Mongolia, Mozambique, Myanmar, Namibia, Nepal, Niger, Nigeria, Pakistan, Papua New Guinea, Philippines, Republic of Moldova, Rwanda, Sao Tome and Principe, Senegal, Seychelles, Sierra Leone, Somalia, South Africa, South Sudan, Swaziland, Timor-Leste, Togo, Tuvalu, Uganda, UR Tanzania, Zambia, Zimbabwe

If you answer YES to ALL four screening questions below a member of our admin team will contact you to book for the screening blood test.

Please note that these tests are available on Thursday mornings.

Are you aged between 16 years and 35 years old? *

Yes No

Did you enter the UK within the last 5 years? *

Yes No

Were you born in, or have you spent more than 6 months over the past 5 years in one of the high risk of TB countries listed above: *

Yes No

If you have answered YES to all 3 screening questions would you like a free screening blood test to check for latent TB *

Yes No

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Latent Tuberculosis Screening Questionnaire

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