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Get GA DPH TB Unit 2011

__________________________________________ (Name, address, city, state, zip, and phone number of place where test was given) Test Date: __________ Results _____ mm Positive __ Negative __ Chest X-Ray: Normal ___ Abnormal ___ Were you treated for: Latent TB infection (LTBI)? Yes __ No ___ #Months ___ TB Disease? Yes __ No __ #Months ___ If yes, When? _________________ Where? _______________________________________________________________ Name of Medications: __________________________________.

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