Are you on the hunt for information about a health status statement form? If so, you’ve come to the right place! A health status statement is an important part of medical care, but can often be confusing. This blog post will guide you through all aspects of this paperwork and explain why it’s vital to have your good health documentation tracked and monitored in order to maintain overall wellbeing. Get ready to learn more about completing these forms efficiently with helpful tips from our team of experts!
Question | Answer |
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Form Name | Health Status Statement Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | 2nd, PCPs, what to write in health status, health status form |
H EALTH STATU S STATEM EN T FORM
N ot ice t o Applica n t :
This phy sician’s st at em ent m ust be com plet ed befor e y ou can begin any assignm ent w it h Max im . Please D O
N OT delay sending y our com plet ed applicat ion and ot her for m s. This st at em ent m ay be sent at a lat er dat e, but m ust be sent pr ior t o t he st ar t of y our em ploy m ent .
APPLI CAN T I N FORM ATI ON : ( Please Pr int )
Nam e: ___ |
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____ |
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Hom e Addr ess: ___ |
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________ |
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Cit y : ___ ___________ |
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St at e: ___ ______________ |
Zip code: _ ______________ |
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TESTS PERFORM ED : ( Applicant m ust hav e TB sk in t est per for m ed unless cont r aindicat ed by MD)
TB Skin Test : Dat e Per for m ed ___ / ___ / ___ * |
Dat e Read ___ / ___ / ___ * |
Result s____ ______ |
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2 n d St ep TB Sk in Test : Dat e Per for m ed ___ / ___ / ___ * |
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Dat e Read ___ / ___ / ___ * |
Result s__ __ __ |
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TB sk in t e st is con t r a in d ica t e d : Ye s_ _ _ N o _ _ _ ( I f y e s r e f e r t o ch e st x - r a y )
Chest X- Ray ( if sk in t est , N/ A) : Dat e Per for m ed ___ / ___ / ___ * |
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Result s/ Ev idence of t uber culosis?: ___ |
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Reason chest x - r ay per for m ed: |
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____ hist or y of posit iv e PPD _ ___ aller gy t o ser um ____ ot her ( pr ov ide det ails) ___ |
_____________ |
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• TB t est r esult s m ust be cur r ent w it hin a y ear of em ploy m ent w it h Max im St affing Solut ions.
•Chest X- Ray r esult s m ust be cur r ent w it hin t w o y ear s of em ploy m ent w it h Max im St affing Solut ions.
I M M U N I ZATI ON RECORD S
Mum ps Tit er or Vaccine: |
Dat e Per for m ed: ___ / ___ / _ __ |
Result s: |
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Rubella Tit er / or Vaccine: |
Dat e Per for m ed: ___ / ___ / _ __ |
Result s: |
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Rubeola Tit er / or Vaccine: |
Dat e Per for m ed: ___ / ___ / _ __ |
Result s: ______________ |
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Var icella: |
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Dat e Per for m ed: ___ / ___ / _ __ |
Result s: ______________ |
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Hepat it is Vaccine 1: |
Dat e Per for m ed: ___ / ___ / _ __ |
Result s: |
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Hepat it is Vaccine 2: |
Dat e Per for m ed: ___ / ___ / _ __ |
Result s: |
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Hepat it is Vaccine 3: |
Dat e Per for m ed: ___ / ___ / _ __ |
Result s: |
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Hepat it is Tit er ( if v ac, N/ A) : |
Dat e Per for m ed: ___ / ___ / _ __ |
Result s: |
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H EI GH T/ W EI GH T ( as applicable, per st at e licensing r equir em ent s) : |
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Height : ___ |
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Weight : ___ |
N/ A: ___ |
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PH YSI CI AN / PRI M ARY CARE PRACTI TI ON ER’S STATEM EN T:
I cer t ify t h at t h e pat ient n am ed abov e has been ex am ined by m e and found t o be in good ph y sical and m ent al healt h . Fur t her m or e, t hey ar e fr ee fr om com m unicable diseases and ar e able t o per for m t h e essent ial fu n ct ion s of t h e posit ion for w hich h e/ sh e is apply in g.
D a t e of e x a m : ___ / ___ / _ __ |
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Ad dit ion a l Com m e n t s: ___ |
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___________ |
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Nam e of Phy sician/ Pr im ar y Car e Pr act it ioner ( PCP) : ___ |
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License # : ___ ___ |
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Phy sician/ PCP’s Addr ess: ___ |
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Cit y : ___ ______________ St at e: ___ ______________ |
Zip code: ___ |
______________ |
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Phy sician/ PCP’s Signat ur e: ___ |
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Dat e: ___ / ___ / _ __ |
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Healt h St at us St at em ent For m