Doctors Hospital - Ohiohealth Immunization Form Page 2
Download a blank fillable Doctors Hospital - Ohiohealth Immunization Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Doctors Hospital - Ohiohealth Immunization Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2Doctors Hospital OhioHealth
History of Positive TB Test - 4
th
Year Elective Rotations
Only fill out this form if you have had a Positive TB test result from one of your two most recent tests (the most
recent test must be within 12 months).
Name:
þÿ
Date of Birth:
SSN:
Phone:
þÿ
þÿ
þÿ
Street Address:
þÿ
City:
State:
Zip:
þÿ
þÿ
þÿ
Today's Date:
Student Signature:
þÿ
Date of positive TB test:
Date of last chest x-ray:
X-ray result:
þÿ
þÿ
þÿ
(A) BCG Vaccine?
(C) INH Therapy?
NO
NO
YES
YES
(B) Treated by physician?
(D) Traveled outside the USA?
When?
NO
NO
YES
YES
þÿ
During the last year, have you experienced any of
NO
YES
RESOLVED?
If not resolved, please comment
the following conditions over a prolonged period
of time?
1. Abdominal or gastrointestinal problems such as
NO
YES
RESOLVED
þÿ
frequent diarrhea, nausea or vomiting.
2. Unexplained weight loss or excessive fatigue.
NO
YES
RESOLVED
þÿ
3. Frequent upper respiratory symptoms such as
NO
YES
RESOLVED
þÿ
colds, sore throat, productive cough, or pneumonia.
4. Persistent fever or excessive sweating, especially
NO
YES
RESOLVED
þÿ
at night.
5. Skin problems such as cold sores, boils,
NO
YES
RESOLVED
þÿ
abscesses or other skin lesions of the face and
hands.
6. Communicable diseases such as Hepatitis or
NO
YES
RESOLVED
þÿ
Tuberculosis.
7. Compromised immune system or serious illness.
NO
YES
RESOLVED
þÿ
8. MEDICATION ALLERGIES:
NO
PLEASE LIST
YES
þÿ
Tests must be read in 48-72 hours. Test read greater than 72 hours will need to be repeated. All employees with positive results must
be evaluated by Associate Health.
Signature: _____________________________ Date:
þÿ
Physicians or allied health practitioners: Your signature authorizes release of this TB testing form to the Medical Staff Office
To be completed by Associate Health
Date of last TB Skin Test ___/___/____
Date Applied
Site
Manufacturer Lot #
Exp. Date
Signature
Date Read
Induration
Signature
1
st
Step
___/___/___
RFA/LFA
___/___/___
___/___/___
mm
2
nd
Step
(if required)
___/___/___
RFA/LFA
___/___/___
___/___/___
mm
This person reports no symptoms suggestive of communicable disease. ____ CLEARED
___ NOT CLEARED
Associate Health & Wellness Physician Signature: __________________________ Date: ___/___/_____
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical