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Initial Mantoux PPD Skin Testing

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Please answer the following questions:

Have you ever had tuberculosis?
Have anyone close to you had tuberculosis?
Have you ever been exposed to tuberculosis?
Have you ever had a reaction to the TB test?
Have you had stomach or intestinal surgery?
Were you born in the continental United States?
Have you ever had BCG vaccination for TB?
How long ago? # of years
Is you immune system working well?
Are you taking steroids or cortisone?
Are you receiving radiation or chemotherapy?

Comments:

I understand that this test is required a s a condition of employment and potential side effects, which are possible as with any medication, have been explained to me. I am currently not pregnant or nursing a baby. I am in good health. I consent to the administration of the Mantoux PPD skin test and I understand that I must report back at the given date for the test to be read.
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Personal Info

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