Form Medical Worksheet Medical Worksheet Chest X-Ray and Classification Medical Worksheet One (Ca

CHEST X-RAY AND CLASSIFICATION
MEDICAL WORKSHEET ONE

For Use in Canada Only

For Use with Main Medical Form - Complete Sections 1 through 5, As Applicable
Name (Last, First, MI.)

Age
Passport Number

Birth Date (mm-dd-yyyy)
1. Chest X-Ray

Alien (Case) Number

(Mark All that Apply)
TB Signs or Symptoms

History of Tuberculosis (TB) Disease
Contact with Person with TB
(If child does not have any of the above, stop here.)
2. Chest X-Ray Findings

Adult (With or Without Any of the Other)
Date Chest X-Ray Taken (mm-dd-yyyy)

Normal Findings
Abnormal Findings

(Indicate findings and interpretation, by checking all that apply, and any other in the table below.)
Can Suggest INACTIVE TB
(Need Smears if Symptomatic)

Can Suggest ACTIVE TB
(Need Smears)
Infiltrate or Consolidation

Discrete Fibrotic Scar or Linear Opacity

Any Cavitary Lesion

Discrete Nodule(s) without Calcification
Discrete Fibrotic Scar with Volume Loss
or Retraction
Discrete Nodule(s) with Volume Loss or
Retraction
Other (Such as Bronchiectasis)

Nodule with Poorly Defined Margins
(Such as Tuberculoma)
Pleural Effusion
Hilar/Mediastinal Adenopathy

OTHER X-Ray Findings

Follow-Up Needed
Musculoskeletal
Cardiac
Pulmonary
Other
No Follow-Up Needed for
Pleural thickening, diaphragmatic tenting,
blunting costophrenic angle, solitary calcified
nodule or granuloma or minor
musculoskeletal or cardiac finding

Linear, Interstitial Markings
Other (Such as Miliary Findings)
Remarks

3. Sputum Smears
No, Applicant has No Signs or Symptoms of TB and :

X-Ray Suggests INACTIVE TB, this is a Class B2/TB
OTHER X-Ray Findings Suggest Follow-Up Needed after Arrival, this is B Other
OTHER X-Ray Findings Suggest No Follow-Up Needed, this is No Class
X-Ray Normal, this is No Class

Yes, Applicant has (Mark All that Apply) :

and Smear Results are:
Positive

Signs or Symptoms of TB Present, See Section 1

Negative

Dates Obtained (mm-dd-yyyy)

X-Ray Suggests ACTIVE TB, See Section 2
Sputum Smear Results and X-Ray
At least One Smear Result POSITIVE and
Any Chest X-Ray Finding, this is Class
(Normal or Abnormal findings)

Three Smear Results NEGATIVE and
X-Ray Normal with
Signs of Symptoms Resolved, this is

No Class

Signs or Symptoms Suggest Follow-Up Needed after Arrival, this is B Other
X-Ray Suggests ACTIVE or INACTIVE TB, this is Class B1/TB
OTHER X-Ray Findings Suggest Follow-Up Needed After Arrival, this is Class B

4.
5.

No Class
Follow-Up

Remarks

Class A/TB

Class B1/TB

Class B2/TB

Class B Other, Follow-Up

Needed After
TB Condition
If Yes, for
Not TB Condition
No
Yes
(If yes, specify condition below and on DS-2053; include additional tests, and therapy used with start and stop dates and any changes.)

Medical
Worksheet One