Tuberculin Skin Test Consent

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

If YES to any of the following questions, please contact our office at 613-966-5486 and do not proceed with online booking.

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., anaphylaxis, blistering, necrosis or ulceration) to a TB skin test? *
Have you had active TB or treatment in the past?*
Have you ever had a positive reaction to a previous TB skin test which was read by a knowledgeable healthcare worker and documented?*
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)?*

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*