Agency TB Consent and Questionnaire |
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1. Have you ever:
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a. Had a TB skin test Yes or No
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b. Had a positive skin test Yes or No
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2. Have you had a TB skin test in the last 12 months? Yes or No
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Are you able to provide written documentation? Yes or No
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3. Have you ever been exposed to TB? Yes or No
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If yes, was this exposure since your last TB test? Yes or No
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4. Do you currently have:
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a. Persistent Cough? Yes or No
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b. Night Sweats? Yes or No
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c. Unexplained weight loss? Yes or No
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d. Coughing up blood? Yes or No
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e. Loss of Appetite? Yes or No
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f. Fever/Chills? Yes or No
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5. Have you received a vaccine of any type? Yes or No
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Was it within the last 24-48 hours? Yes or No
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(if yes to any of the above, skin test cannot be given until 4-6 weeks from the date of vaccination and must obtain documentation from MD that you are free of communicable disease.
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Are you currently on prolonged corticosteroid therapy,
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Immune-suppressant therapy, or have a diagnosis of Sarcoidosis? Yes or No
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(if yes, must have documentation from MD that you Are free of communicable disease?
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By signing below, I agree to allow this agency to administer the TB Mantoux skin test to me and release the agency from any liability in connection with the administration of this test.
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STEP 1: |
Mantoux test site: __right forearm __ left forearm __ other ( )
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mm
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mm
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STEP 2: |
Mantoux test site: __right forearm __ left forearm __ other ( )
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mm
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mm
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