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Get VA TB 512 2012

______________________ DOB: _______________ Social Security Number: ______________________ City, State, ZIP: ____________________________________________________________ Cell #: ___________________ Language: _____________________ Home/Work #: _____________________ Patient Pregnant: ___No ___Yes; Country of Origin: _____________________________ Year arrived in US (if applicable): ________ I. Screen for TB Symptoms (Check all that apply) ___None (Skip to Section II, “Screen for Infecti.

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