Medical Screening (men)

Mt Zion House MEDICAL SCREENING

This form must be completed by the applicant and his physician, physician’s assistant, registered nurse, or nurse practitioner prior to entry into the Mt Zion House residential program.

Name:

Date:

Date of Birth:

Tuberculosis test: Positive____ Negative____ PPD____ Chest x-ray____

HIV test: Positive____ Negative____

Syphilis test: Positive____ Negative____ Treated____ Medicine__________________

Gonorrhea test: Positive____ Negative____ Treated____ Medicine__________________

Chlamydia test: Positive____ Negative____ Treated____ Medicine__________________

Hepatitis A Antibody Positive____ Negative____

Hepatitis B Antibody Positive____ Negative____

Hepatitis B Surface Antigen Positive____ Negative____

Hepatitis C Core Antibody Positive____ Negative____

AUTHORIZATION

I, ______________________________ authorize the above medical tests to be done and the results of such tests to be released to Mt. Zion House, 2330 Hwy 120, Lake Geneva, WI 53147

Resident/Patient__________________________________Date____________________

EXAMINATION RESULTS

Upon visual examination of________________________________________ I have found him to be free from
clinically apparent communicable diseases and to be in physically excellent, average, poor health (circle one)

 

Physician or Nurse (please print)______________________________________Date____________________

 

Physician or Nurse Signature______________________________________Phone:__________________

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