• TB Form Questionnaire

  • Pregnant*
  •  -
  • Date
     - -
  • Ever Had an Adverse Reaction to TB Skin Test*
  • Ever Infected with TB les than 2 Years Ago*
  • Undernourished/Underweight*
  • End Stage Renal Disease, Diabetes or Silicosis*
  • Immune Suppressed*
  • HIV Infected*
  • Contact with Known Infected Person w/TB*
  • History of Substance Abuse*
  • Told to have Scarring/Fibriosis on Chest X-Ray*
  • Treated for active TB*
  • Treated for latent TB*
  • Ever had a TB blood test*
  • Ever had a BCG vaccine*
  • Positive reaction to TB test*
  • Born out of USA*
  • Lived out of US less than 5 years*
  • Traveled/Lived out of USA in 2 years*
  • Are you a Healthcare Worker*
  • Volunteered/Worked in nursing home, prison or other residential instituion*
  • Please check all that are applicable

  • I have received information about TB skin test. I had a chance to ask questions which were answered to my satisfaction. I agree to return in 48-72 hours to have the test read. I understand the risks and benefits of the TB skin test and request that the test be given to me. I understand that if I am symptomatic for TB or if the TB skin test is positive, results may be communicated to the physician with whom I will follow-up if medical care is needed.

  • Clear
  • Should be Empty: