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Get VA TB 512 2005

Er:_________________________ Ethnicity: Cell Phone #: Race: Country of birth: Year of US arrival (if applicable): Language(s) spoken: Interpreter needed? ____No ____Yes Is patient pregnant? ____No ____Yes History of Prior BCG? ___No ___Yes Specify year:_________ Drug allergies: LMP: ___/___/___ History of TB Skin Test and TB Treatment ___None (Skip to Section II, “Screen for Infection Risk”) Prior TB treatment? ___Cough for > 3 weeks ___Fever, unexplained ___Hemoptysis ___.

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