Agency TB Consent and Questionnaire

Agency TB Consent and Questionnaire

1. Have you ever:

a. Had a TB skin test Yes or No

b. Had a positive skin test Yes or No

2. Have you had a TB skin test in the last 12 months? Yes or No

Are you able to provide written documentation? Yes or No

3. Have you ever been exposed to TB? Yes or No

If yes, was this exposure since your last TB test? Yes or No

4. Do you currently have:

a. Persistent Cough? Yes or No

b. Night Sweats? Yes or No

c. Unexplained weight loss? Yes or No

d. Coughing up blood? Yes or No

e. Loss of Appetite? Yes or No

f. Fever/Chills? Yes or No

5. Have you received a vaccine of any type? Yes or No

Was it within the last 24-48 hours? Yes or No

(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.

Are you currently on prolonged corticosteroid therapy,

Immune-suppressant therapy, or have a diagnosis of Sarcoidosis? Yes or No

(if yes, must have documentation from MD that you Are free of communicable disease?

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.

STEP 1:

Mantoux test site: __right forearm __ left forearm __ other ( )

STEP 2:

Mantoux test site: __right forearm __ left forearm __ other ( )