Republic of the Philippines
Province of Occidental Mindoro
MUNICIPALITY OF ABRA DE ILOG
MUNICIPAL HEALTH OFFICE
TUBERCULOSIS SKIN TEST (MANTOUX) FORM
Patient Name: _____________________________________ Age: _______ Sex:______
Index patient:
Bacteriologically confirmed Clinically diagnosed
TB exposure:
Household contact
Close contact with TB risk
Close contact without TB risk
PLHIV ≥ 1 year old
Other risk groups (please specify):___________________
Is the patient immunocompromised/malnourished (Please encircle)? Yes | No
Testing Location: _____________________________________________________
Date performed: ___________________ Date read: _____________________
Site: Left arm Right arm Induration (in mm): _____________
Administered by (Signature over printed name): ____________________________________
PPD RESULT
Plan:
Automatically enroll to TPT due to history
For enrollment to TPT due to positive PPD
For Chest X-ray
For further assessment and management
_________________________________________________________________
CONSENT
By signing this form, I acknowledge that I have received the complete information about PPD
testing from the Municipal Health Office of Abra de Ilog and I give my full consent and
permission to administer a Mantoux Test.
_________________________________________
Signature over Printed Name of Patient or Guardian
E - ma i l : L GU: l g u . a b r a d e i l o g @ g ma i l . c o m
MHO: a b r a d e i l o g . mh o @ g ma i l . c o m
We b s i t e : w w w . a b r a d e i l o g . g o v . p h
