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Get GA DPH TB Unit 2016-2024

________________________________________________________ (Name, address, city, state, zip, and phone number of place where test was given) Test date: ______ Results___mm Positive/Negative/Indeterminate Were you treated for: Chest x-ray Normal/Abnormal ___________ Latent TB Infection (LTBI) Yes/No If yes, # of months treated: _____________ TB Disease Yes/No If yes, # of months treated: _____________ When/Where _________________________________ __________________________________ Medications used.

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