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4 Bethesda Hospital
BAPTIST HEALTH SOUTH FLORIDA
RECORD OF TB SKIN TEST
NAME: Dept/Ext: Volunteer_Date
PPD HISTORY: OONEGATIVE O POSITIVE MM — (BCG VACCINE
IF PREVIOUS POSITIVE: WERE YOU GIVEN MEDICATION 0 YES ONO
FOR HOW LONG
SCREEN & SYMPTOMS REVIEW: (DO YOU HAVE ANY OF THE FOLLOWING)
PRODUCTIVE, PERSISTENT COUGH OF 2-3 WEEKS DURATION Yes No
BLOODY SPUTUM (MUCOUS) ves No
NIGHT SWEATS ves No
WEIGHT LOSS WITHOUT DIETING Yes No
LOSS OF APPETITE ves No
EASY FATIGABILITY (TIREDNESS) Yes No
FEVER ves No
IN THE PAST YEAR HAVE You:
GAINED 10 POUNDS OR MORE yes No
EXPERIENCE ANY FACIAL INJURYISCARRING Yes No
HAD A CHANGE IN DENTAL STRUCTURE Yes No
GROWN/SHAVED FACIAL HAIR Yes No
VOLUNTEER SIGNATURE.
PPD PLANTED: OLEFT RIGHT READ: 0148 HOURS 72 HOURS
PPD GIVEN BY
48 HOURS 72 HOURS
ERYTHEMA: OYES ONO __MM OYES ONO ___MM
INDURATION: OYes ONO __MM OYes ONO __MM
READ BY:
CXR ORDERED DATE
RESULTS
