|
Date
|
Name
|
|
DOB
|
School
|
|
Persistent Cough?
|
Weight Loss w/o Dieting?
|
|
Night Sweats?
|
Loss of Appetite?
|
|
Persistent Fever?
|
Chest Pain?
|
|
Chronic Fatigue?
|
Coughing Up Blood?
|
|
Have you ever had a reaction (induration) to a TB skin test/.
|
If yes, what year?
|
|
Have you ever had an abnormal TB lab test? (Q, Gold, or T-spot)?
|
If yes, what year?
|
|
Have you ever taken medications for TB (Isonazid [INH])?
|
If yes, what year?
|
|
Have you ever had BCG vaccine/inoculation for TB?
|
If yes, what year?
|
|
Have you ever been told your Chest X-ray was abnormal?
|
If yes, what year?
|
|
Are you pregnant or breastfeeding?
|
If yes, pregnant, breastfeeding, or both?
|
|
As far as you know have you recently been exposed to TB?
|
If yes, what year?
|
|
Are you immunocompromised (more susceptible to illness)?
|
If yes, please explain.
|
|
Signature
|
Date
|
|
Purified Protein Derivative (For Office Use Only)
|
|
|
Site
|
Amount
|
|
Lot #
|
NDC:
|
|
Manufacturer
|
Exp
|
|
Admin. By
|
Date/Time Admin.
|
|
Test Read
|
|
|
Date and Time Read:
|
Results in MM
|
|
Interpretation
|
Read By
|
|
Read By Signature
|
Date
|
