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:__________________