Get What Should I Write In Health Status

Date of exam // Additional Comments Name of Physician/Primary Care Practitioner PCP License Physician/PCP s Signature Health Status Statement Form Date //. HEALTH STATUS STATEMENT FORM Notice to Applicant This physician s statement must be completed before you can begin any assignment with Maxim. Please DO NOT delay sending your completed application and other forms. This statement may be sent at a later date but must be sent prior to the start of your employment. APPLICANT INFORMATION Please Print Name Home Address City State Zip code TESTS PERFORMED Applicant must have TB skin test performed unless contraindicated by MD TB Skin Test Date Performed // Date Read // 2nd Step TB Skin Test Date Performed // TB skin test is contraindicated Results Yes No If yes refer to chest x-ray Chest X-Ray if skin test N/A Date Performed // Results/Evidence of tuberculosis Reason chest x-ray performed history of positive PPD allergy to serum other provide details TB test results must be current within a year of employment with Maxim Staffing Solutions. Chest X-Ray results must be current within two years of employment with Maxim Staffing Solutions. IMMUNIZATION RECORDS Mumps Titer or Vaccine Rubella Titer / or Vaccine Results Varicella Hepatitis Vaccine 1 Hepatitis Titer if vac N/A HEIGHT/WEIGHT as applicable per state licensing requirements Weight N/A PHYSICIAN/PRIMARY CARE PRACTITIONER S STATEMENT I certify that the patient named above has been examined by me and found to be in good physical and mental health. Furthermore they are free from communicable diseases and are able to perform the essential functions of the position for which he/she is applying. This statement may be sent at a later date but must be sent prior to the start of your employment. APPLICANT INFORMATION Please Print Name Home Address City State Zip code TESTS PERFORMED Applicant must have TB skin test performed unless contraindicated by MD TB Skin Test Date Performed // Date Read // 2nd Step TB Skin Test Date Performed // TB skin test is contraindicated Results Yes No If yes refer to chest x-ray Chest X-Ray if skin test N/A Date Performed // Results/Evidence of tuberculosis Reason chest x-ray performed history of positive PPD allergy to serum other provide details TB test results must be current within a year of employment with Maxim Staffing Solutions. Chest X-Ray results must be current within two years of employment with Maxim Staffing Solutions. IMMUNIZATION RECORDS Mumps Titer or Vaccine Rubella Titer / or Vaccine Results Varicella Hepatitis Vaccine 1 Hepatitis Titer if vac N/A HEIGHT/WEIGHT as applicable per state licensing requirements Weight N/A PHYSICIAN/PRIMARY CARE PRACTITIONER S STATEMENT I certify that the patient named above has been examined by me and found to be in good physical and mental health. Chest X-Ray results must be current within two years of employment with Maxim Staffing Solutions. IMMUNIZATION RECORDS Mumps Titer or Vaccine Rubella Titer / or Vaccine Results Varicella Hepatitis Vaccine 1 Hepatitis Titer if vac N/A HEIGHT/WEIGHT as applicable per state licensing requirements Weight N/A PHYSICIAN/PRIMARY CARE PRACTITIONER S STATEMENT I certify that the patient named above has been examined by me and found to be in good physical and mental health. Furthermore they are free from communicable diseases and are able to perform the essential functions of the position for which he/she is applying.