Tuberculin Questionnaire
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1TUBERCULIN SKIN TEST QUESTIONNAIRE AND CONSENT
NAME_____________________________________________DATE_______________________
ADDRESS_________________________________________ BIRTHDATE_________________
Please circle yes or no:
In the past 6 weeks have you
Had chicken pox, measles, mumps or influenza
Yes
No
Received corticosteroid medications
Yes
No
Received measles, mumps, or influenza vaccine
Yes
No
In the past 3 months have you received immunoglobulin
Yes
No
Have you
Had close recent contact with someone with TB
Yes
No
Had a chest Xray consistent with TB
Yes
No
Had a positive test for HIV
Yes
No
Had sexual contact with someone of the same sex
Yes
No
Used injectable drugs
Yes
No
Had sex with a bisexual person
Yes
No
Do you have hemophilia
Yes
No
Have you ever
Lived in Asia, Africa, or Latin America
Yes
No
Resided in a nursing home, prison, or mental institution
Yes
No
Been Homeless
Yes
No
Do you have
Silicosis or diabetes mellitus
Yes
No
Leukemia, lymphoma, Hodgkins disease or other cancer
Yes
No
Chronic renal failure or kidney disease
Yes
No
Weight loss to 10% or more below ideal body weight
Yes
No
Night sweats
Yes
No
Have you had
A gastrectomy or jejunoilial bypass
Yes
No
Have you ever had a positive TB test
Yes
No
I ask that I, or the person named above for whom I am authorized to make this request, be give a
tuberculin skin test:
Signature: ___________________________________________________________
__________________________________________________________________________________________
Office use only
Date test planted____________ Lot #________________Manufacturer: Aventis Pasteur
Antigen Strength 5TU/o.1ml
Dosage/Route/Site: 0.1 ml/intradermal/___forearm
Signature of test administrator_________________________________________
Date test read:___________
Results:____________________mm induration
Signature of test reader________________________________________________
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Parent category: Medical