%S Mercy Medical Group. JOHNSON HEATHER L_mRU-374504 | Service of Dignity Haales Medical Foundation pap Ly Sicramentn ca PT A oo 555 Coyle Avenue ceaicara ren Si armichael, CA 95608 peste nen 16-36-3920 PETROVICH OO,ANNA 7102 DATE: 09/01/2015 Ve: 19676650 uberculosis Screening Questionnaire ave you ever had a positive TB test? - Gyes gino ave you ever received the BCG (tuberculosis) vaccine? yes Ono ave you had any recent exposure to tuberculosis? yes Gino ave you had any of the follewing symptems ower the past few months? Fevers yes Bn Chilis Byes mine Night sweats Dyes wine Weight Loss Byes Fino Cough yes fino Shortness of Breath yes gna Placement sogfor {IE time_t1 B0am om YAS Tine fl 5 SohtArm Len Arm induration <2 _ mm x ni Tubersol Lott Tle 20L0 _ exp 2417 9 Be a rinistered by: Abigacl Mexia eit fight Arm = SV Le Arm ster Tubersol Lott tinistered by: wr TB test was place on OF for / 1S at__ LE O0apampm. ease retun ater PBS 11.00 or vetore Pf fee for official reading oe Yor ood = ‘ease bring this form with you when you return for your reading, Induration mm x Interpreted by: me Date Time,