Medical Screening Form

Pastor John LaGalbo
Director
2330 Highway 120
Lake Geneva, WI 53147

Mt. Zion House
web-site - www.mtzionhouse.org
Toll-free (866)468-9466
Facsimile (262)249-8903
Telephone (262)249-8934

Medical Screening Form

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

Name ______________________________ Today's Date__________Date of Birth_____________

Tuberculosis test: ----Positive_______ Negative______ PPD_______ Chest X-ray_________

HIV test: -----Positive_________Negative_______

VD test:------ Positive____ Negative____Treated/Medicine_____________________

Hepatitis panel lab test:

Hepatitis A Antibody
Hepatitis B Antibody(igm)
Hepatitis B Surface Antigen
Hepatitis C Core Antibody

Positive_______Negative_________
Positive_______Negative_________
Positive_______Negative_________
Positive_______Negative_________

I,______________________ authorize the above medical test to be done, and the results of the test to be released to Mt. Zion House of Lake Geneva, WI.

________________________________
Student/Patient

________________________
Date

Examination Results

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

______________________________
Signed - Physician/Nurse

______________________________
Please print - Physician/Nurse

_______________________
Date

_________________________
Medical facility/contact #

Pastor John LaGalbo Director 2330 Highway 120 Lake Geneva, WI 53147			Mt. Zion House web-site - www.mtzionhouse.org Toll-free (866)468-9466 Facsimile (262)249-8903 Telephone (262)249-8934

Medical Screening Form This form must be completed by applicant and his physician's assistant, nurse practitioner or a registered nurse prior to entry into the Mt. Zion House residential program. Name ______________________________ Today's Date__________Date of Birth_____________ Tuberculosis test: ----Positive_______ Negative______ PPD_______ Chest X-ray_________ HIV test: -----Positive_________Negative_______ VD test:------ Positive____ Negative____Treated/Medicine_____________________
Hepatitis panel lab test:	Hepatitis A Antibody Hepatitis B Antibody(igm) Hepatitis B Surface Antigen Hepatitis C Core Antibody			Positive_______Negative_________ Positive_______Negative_________ Positive_______Negative_________ Positive_______Negative_________

I,______________________ authorize the above medical test to be done, and the results of the test to be released to Mt. Zion House of Lake Geneva, WI.
________________________________ Student/Patient			________________________ Date
Examination Results Upon visual examination of ___________________________, I have found him to be free from clinically apparent communicable diseases and to be in (circle one) excellent/average/poor health physically.
______________________________ Signed - Physician/Nurse ______________________________ Please print - Physician/Nurse		_______________________ Date _________________________ Medical facility/contact #