Two-Step TB Test Form
Please complete this form to provide information and consent for your two-step tuberculosis (TB) test procedure.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Have you ever had a tuberculosis (TB) test before?
*
Yes
No
Have you ever received the BCG vaccine?
*
Yes
No
Not sure
Do you have any symptoms suggestive of TB (such as persistent cough, night sweats, unexplained weight loss, fever)?
*
Yes
No
Are you currently immunocompromised or taking immunosuppressive medications?
*
Yes
No
Not sure
Step 1: Date of first TB test placement
*
-
Month
-
Day
Year
Date
Step 1: Date of first TB test reading
*
-
Month
-
Day
Year
Date
Step 2: Date of second TB test placement
*
-
Month
-
Day
Year
Date
Step 2: Date of second TB test reading
*
-
Month
-
Day
Year
Date
Please list any allergies or current medications (if none, write "None")
*
Signature of Patient or Legal Guardian
*
Submit
Submit
Should be Empty: