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BATCH AMOUNT:
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PT:
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Country of birth:
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Age:
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Current country of residence:
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BCG vaccination record:
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Previous exposure/contact with active TB
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Primary immunoglobin antibody response:
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Anti-M. TB antigens:
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IGRA test result:
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TST size:
AIDS
Underweight (<90% of ideal or BMI <20)
Abnormal chest x-ray (granuloma form)
Abnormal chest x-ray (fibronodular disease)
Carcinoma of head and neck
Chronic renal failure; hemodialysis treated
Diabetes Mellitus (all types acceptable)
Transplantation (req. immune-suppressant)
Prev. glucocorticoids treatment
Tumor necrosis factor alpha inhibitors
Silicosis
Cigarette smoking history (>1 pack/day)
Please select all that apply:
SUBMIT
SUBMIT FILE(S)
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GROUP: