AccEsstnb TUBERCULIN SKIN TEST (TST) REPORT
Name: ______Date: ___,! ___ ~/ __
S.S.N.: ______Date of Birth __/ __/__ Sex: 0 Male 0 Female
Phone: ( } __ - Employer: ------Reason for Testing: __?replacement __Annual __Post Exposure __Immi gration QUESTIONS 1. Have you ever had a TB skin test before? __Yes __No __I do not know If yes, was it ever positive _ _ yes __No __I do not know If it was positive, how long ago and where did you receive this test: ------ Did you receive any treatment or medication forTS? ------Do you have any of the following: a. Sensitivity f allergy to PPD serum? __Yes --No b. Received polio vaccine in the last 4-6 weeks? __Yes __No c. Received MMR in the last 4-6 weeks? __Yes __No d. Received varicella vaccine in the last 4-6 weeks? __Ye s __No e. Receiving corticosteroidfother immunosuppressive therapy? __Yes --No 3. Have you ever received BCG vaccine? __Yes _ _ No If yes, how long ago and where did you receive this inoculation: ------*****You must return within 48-72 hours to have the test results read. ***** Before: __.__ Return On:----''-----''-- After: _____ OR ------''---''-- I have read and understand that these are the only times in which this TB test will be accurately read.
Signature: Date: I I --nte patient named above has been tested for exposure to Tuberculosis using Purified Protein Derivative diluted to equal standard 5 Tuberculin Units, in the amount of 0.1cc intradennally. This is the standard Mantoux test
Date of Placement ___,/ / ___ Time of Placement ____. ___ location of Placement: 0 Right Forearm 0 left forearm 0 Other Site______Lot#: Exp. Date: !__ _, ! Manufacturer:------
Placed By: R.N.
Date of Reading: I I ___ Time of Reading: ____. _____ RESULTS: 0 Negative _ MM 0 Positive __MM - 0 This person has completed negative (Omm) testing. 0 Incomplete testing, failed to return at specified time. 0 Requires 2-step testing 0 Yes 0 No Return for #2 on __!__ ! __ 0 Chest X-ray done 0 Yes 0 No Result: ------0 Referred to PMD or County Health Department for possible medication and/or treatment
Reading Completed by: ------R.N./ M.D.