Forms TB Questionnaire Please indicate your answer to each question. This information is necessary to correctly interpret the result of your tuberculin skin test, or in some cases may indicate you should not receive a tuberculin skin test. Name* First Last Job TitleSocial Security #*Date of Birth* MM DD YYYY 1. Have you ever had a positive tuberculin skin test? If yes, what month and year?* Yes No Date MM DD YYYY 2. Have you ever taken medications for the prevention or treatment of tuberculosis?* Yes No What year were they taken?How long did you take them?3. Are you an organ transplant recipient?* Yes No 4. Have you ever had an abnormal chest x-ray suggestive of tuberculosis or evidence of latent disease?* Yes No 5. Have you taken steroids, immunosuppressants or cancer drugs in the past 30 days?* Yes No 6. Have you received a live vaccine (MMR< Varicella, Flumist) within the past 30 days?* Yes No 7. Are you allergic or medically contraindicated to the Mantoux PPD skin test?* Yes No 8. Were you born outside of the United States?* Yes No If so, what country?Please check any of the following symptoms you are currently experiencing that are unrelated to prior health issues:* I have no symptoms Fever Shortness of breath Chest pain Night sweats Chronic cough Sputum (productive cough) Bloody Sputum Loss of appetite Unintentional weight loss Unusual fatigue By signing below, I attest that all answers above are true and correct to the best of my knowledge. I understand that if a tuberculin skin test is placed it must be read between 48-72 hours after placement. I further affirm that any questions or concerns have been answered to my full satisfaction.Signature*Use your mouse or finger (if on a mobile or tablet device) to draw your signature.Signature Acceptance: I certify that the above information is accurate and complete.*If the signature box above is not working on your device, this field will serve as your electronic signature. Yes EmailPlease enter your email to receive a copy of the completed questionnaire.