Healthcare Health Screening Report

HEALTHCARE HEALTH SCREENING REPORT

Patient Information

Patient Name:

Date of Birth:    Gender:

Insurance Information

Medical History

Screening & Vital Signs

Screening Date:

Blood Pressure:    Pulse:    Respiratory Rate:

Temperature:    Height:    Weight:    BMI:

Screening Tests & Results

TB Test Performed    Result:    Date:

Rapid Diagnostic Test Performed    Result:    Date:

Chest X-Ray Performed    Result / Impression:

Assessment, Recommendations & Follow-up

Screening Summary:

Follow-up recommended

Immunizations

Influenza:    Tetanus:    Hepatitis B:

Clinician Information

Authorization, Consent & Privacy Acknowledgment

By signing below I certify that the information provided is true and complete to the best of my knowledge. I consent to the screening procedures documented herein and authorize the clinicians to perform those procedures and to document the results.

I authorize the release of screening results and pertinent medical information to the following entities as necessary for treatment, payment, or operational purposes:

I acknowledge that I have been offered the facility's Notice of Privacy Practices, and I understand my rights with respect to protected health information. This authorization is valid until: . I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance on this authorization.

I acknowledge receipt of the Notice of Privacy Practices and consent to the uses and disclosures described above.

I consent to the treatment and screening procedures described in this report.

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