Complete entire card. Indicate not applicable or unknown where appropriate. Phone # Name (Last, First, MI) Phone (H) (W) Address Date of Birth Male City, State, Zip Race/Ethnicity Country of Birth Former TB Client? Previous Reactor? Date of Previous Test No Yes No Yes Reason for Test (employment, refugee, etc.) Date TST Planted Date Read Results X-ray Date (within 2 wks of X-ray Results MM Date of IGRA Name of Test Results Medication Prescribed Name of.
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