Policy Manual sample

MDT Home Health Care Agency, Inc. MEDICAL EXAMINATION CERTIFICATE Date:____________________ Name: Sex: Marital Status: Address: Telephone: The following information is required by the Department of Health, Title XXII, Chapter I, Section 70723, for all persons working in the health field: PHYSICAL EXAMINATION (to be completed by physician) Height Weight Blood Pressure Pulse Physical Exam: T.B. Test __________ __________ MANTOUX Test Result __________ Chest X-ray (if indicated) EKG (if indicated) Date Urinalysis VDRL (RPR) Other Lab/Results / Any Communicable Disease: I have examined the above-named individual and I certify that he/she is mentally and physically able to perform the duties of his/her job. I further certify that he/she is free from communicable disease. Physician's Name Physician's Signature Date Physicians Address Telephone Home Health Agency. - - Personnel/Operations Policies B-30