Tuberculin Skin Test Consent

Tuberculin Skin Testing (TST) is administered as in aid in the detection of infection with M. tuberculosis.

Possible Side Effects:
Side effects are rare. Vesiculation, ulceration or necrosis may appear at the test sit in highly sensitive persons. There have been reports of rare systemic allergic reactions manifested by skin rash within 24 hours. Should these side effects occur, seek immediate medical attention.

 

Have you had a previous severe reaction (e.g., blistering, necrosis or ulceration) to a TB skin test? *
Have you had active TB or treatment in the past?*
Do you have active eczema or severe burns? *
Have you ever had a positive reaction to a previous TB skin test which was read by a knowledgeable healthcare worker and documented?*
Have you ever experienced a serious allergic reaction (anaphylaxis) to a previous TB skin test?*
Do you have an allergy or hypersensitivity to any component of Tubersol [Tuberculin Purified Protein Derivative (Mantoux)] (i.e. isotonic phosphate buffered saline, purified protein derivative of M. tuberculosis, Tween 80, Phenol)? *
Within the past month, have you contracted any of the following illnesses: measles, mumps, chicken pox, infectious mononucleosis, typhoid, brucellosis, influenza or whooping cough (pertussis)?*
Have you recently had immunization with a live viral vaccine (e.g., MMR -measles/mumps/rubella, varicella vaccines)?*
Have you had an unexplained fever?*
Do you have Hodgkin's disease, sarcoidosis or have you been infected with HIV?*
Are you taking corticosteroids or immunosuppressive drugs? *
Do you have severe metabolic disturbances, such as chronic renal failure, or severe protein deficiency? *

I have read and understood all information provided to me and my questions have been answered to my satisfaction.

I authorize any registered nurse (RN) or physician from Walsh & Associates Occupational Health Services Ltd. to administer TST.

I agree to seek immediate medical attention, if I should develop any health problems following the administration of the TST (such as difficulty breathing, facial swelling, high fever, muscular weakness or hives).

I will return to the Occupational Health Services on the dates provided to me by the RN for reading of the TST.*
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Birthday*
  
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Validation Code