FIN: 0037-1 8992-71 56

(fiffiKB*RCY
Name:
Addresr RICE, SARA KELLI.MARIE
DOB: 04117/1995 F 22y Lab DTM:
Insuran
ATT: VENTURA, MICHAEL S
SAINI JoSEPH MERCY HEATTH SYSTEM
DOB o1
llllllllllll lllilllll lllllilil rmN: 0,2270020

B Urgent Care-Lake Orion tr Urgent Care-Waterford tr Urgent Care-White Lake

1375 South LapeerRd. 5210 Highland Rd. 320 Town Center Blvd"
Suite 106 Waterford, };4I48327 White Lake MI48386
Lake Orion, MI 48360 (248) 673-2474 (248) 758-7800
(248) 693-9040 (248) 618-0355 fax (248) 698-4281 fax
(248) 693-9007 fax

Tuberculin (TB) Skin Test (PPD O.lcc intradermal)

Reason for skin test today: (, \-'r l., /Trzr{er ns l-r i p
Consent to Test:

I have received information regarding TB skin testing and have had the chance to ask questions that were answered to my satisfaction. I
understand that the skin test involves injecting a small amount of diagnostic antigen under the inside skin of my forearm.
As a result, a
small bruise and/or slight bleeding may occur. I asree to return in 48-72 hourJ to have the skin test read. irailure to return
to have
TB,test read mav be a barrier for emnlovment. I understand that if the fe stiin test is posltire, t may neeO a nrrtt e. meOica-
evaluation.

*a*a Eds
Signature
Juae 5 , &al1
Date

Circle any of the below symptoms you may be experiencing today:

Cough Coughing up blood f,'ever Loss of WeighUAppetite Fatigue/Tiredness Night sweats

PI.EASE ANSWER THE FOLLOWING QUESTIONS:

Have you ever had a positive TB skin test? Yes @ Administration

Have you ever taken medication for tuberculosis?
Have you had the BCG vaccine?
Yes @
Yes
Have you ever had a severe reaction to a TB skin test?

ffi
Yes
Have you been in contact with someone who has TB? Yes
Do you have any of the following risk factors?
HIV Yes @
Diabetes Yes
Long term steroid use Yes Interpretation
Malnutrition Yes ffi
Gastrectomy Yes e
Kidney disease Yes @
IV Drug Use Yes @
Chemotherapy Yes (E l,;.,,,i ] .:tl

***Please return betwee"

G'7-t1 J},j@p^r b87-L TOra?@p^to have your test read***

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Location(circley,arOff'ilfr g.isht Foreaqm - ^ ltlA Location(circle): r-JG
Manufacturer/t-otF;6pes,pgJ^ / e So 3{P
Expiration date: t
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Administered by:
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Interpretation:
Interpreted/Read by:

> 5 mm is positive for:
Patients suspected of HIV infection
Recent/close contact with person with infectious TB
Patients with organ transplants
Patients on immunosuppressive medications
ar"[,;-,{,t8 - 7 8
) l0 mm is positive for: > 15 mm is positive for:
Populations at elevated risk (irnmigrants, specific ethnic groups Patients with no known risk factor.s
Residents oflong term care facilities (conectional facilities included)
Children younger than 4 years of age
Individuals with above mentioned risk factors