RECORD OF PHYSICAL EXAMINATION
NAME: ___________________________________________________________________________++++___________
ADDRESS: _______________________________________________________________________________________
Height __________________Weight _____________Blood Pressure __________________
Pulse______________
Are there any signs of illness/abnormalities of the following: (If “yes” please provide description in space provided)
Skin
___NO ___Yes ___________________________________
Lungs
___NO ___Yes ___________________________________
Heart
___NO ___Yes ___________________________________
Ears/Nose/Throat
___NO ___Yes ___________________________________
Abdomen
___NO ___Yes ___________________________________
Lymph Nodes
___NO ___Yes ___________________________________
Extremities
___NO ___Yes ___________________________________
Neurological System
___NO ___Yes ___________________________________
Is there are pertinent history or condition that is being treated:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Examining Physician _________________________________________Phone: _____________________
PLEASE PRINT
Examining Physician’s Signature ________________________________________________Date: ______________
ANNUAL TB SCREENING TEST FORM
Name:
REQUIRED: ANNUAL PPD – MANTOUX TEST
This test can be done at the Employee Health Office of HealthAlliance Hospital: Broadway Campus. Please call 334-2769 for
hours. If you have had the test elsewhere, you must submit a certified copy of your test results to the Medical Staff Office
of HealthAlliance Hospital: Broadway Campus.
The test must be certified by a NYS Licensed Practitioner OTHER THAN THE APPLICANT/MEMBER.
Date Administered:
Injection Site:
Brand and Lot Number:
Date Read:
Results:
Certified by:
Signature:
PLEASE PRINT NAME
BE CERTAIN TO HAVE TEST READ WITHIN 48 HOURS
Chest X-ray indicated? Yes
No
If indicated, test date:
(Attach copy of report)
TB POSITIVE OR BCG VACCINATION
NOTE: If it has been longer than 10 years since you received the BCG vaccine, you must be retested. Please submit the
results along with this application.
If you are TB Positive, please complete this questionnaire.
Please check any of the following symptoms that you may be experiencing:
______ Loss of appetite
______ Fatigue
______ Fever
______ Weight loss
______ Chronic cough
______ Blood tinged sputum
______ None of the above
______Night sweats
Signature: _________________________________________________________________
Print Name: ___________________________________________________
PHYSICAL AND MENTAL CAPACITY STATEMENT
TO:
Credentials Committee
In my observations of ________________________________I have not received credible information
nor have I seen evidence of impairment of physical or emotional health, including habituation or addiction
to any substance that could interfere with the performance of the privileges requested.
DO NOT SIGN THIS FORM
It must be signed by your Personal Physician or another physician who can attest to your physical and mental capacity.
Physician (Print name)
Physician signature
Phone: ____________________________
Date
NOTE: Initial applicants may have their health status confirmed by the director of a training program, the chief of
services, or chief of staff at another hospital at which the applicant holds privileges, or a currently licensed
physician..
PERSONAL INITIAL HEALTH ASSESSMENT
Name
Answer all of the following questions. If your response to any question is “yes,” please provide a written explanation on
a separate sheet.
1.
Present health status:
Good
Fair
Poor
(if fair or poor, please state reasons on a separate sheet)
2.
Have you consulted a physician or sought medical treatment for any reason
in the last year?
Yes_____ No _____
3.
Have you been hospitalized for any reason in the last year?
Yes_____ No _____
4.
Have you been habituated to drugs or alcohol in the last year?
Yes_____ No _____
5.
Have you been denied or have you had any limitations on your health,
life, or disability insurance in the last year?
Yes_____ No _____
Are you currently taking any medication that may affect your clinical
judgment or motor skills?
Yes_____ No _____
7.
Are you currently under any limitations in terms of activity or work load?
Yes_____ No _____
8.
Are you currently under the care of a physician?
Yes_____ No _____
6.
10. Rubella (German Measles): Titre: Date done:
Results:
Submit serologic proof (copy of lab slip)
Negative titre requires immunization consistent with good medical practice.
11. Rubeola (Measles): Only required for those born on or after 01/01/1957
12. Hepatitis B Vaccine: Date: _________________
12. Varicella (Chicken Pox): Titre: Date done: _________________ Results: _____________________
Show proof of:



TWO measles or MMR vaccinations given after 1st birthday and at least one month apart; OR
Physician-diagnosed disease; OR
Serologic proof of immunity (attach copy of lab slip)
Immunization dates: #1
Disease Date:
APPLICANT’S SIGNATURE:
#2
Titre Date:
DATE: