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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