Form Rfa 07 - Health Screening For County/agency
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2Resource Family Approval (RFA)
Health Screening for County/Agency: __________________________
Purpose of Form: To verify applicant’s physical health. Must be completed by a licensed health professional.
Applicant Name: (first, middle, last)
Date of Birth:
Please provide listing of current licensed health professionals (Name, Address, and Telephone Number)
Physician: ________________________________________________________
Specialist: ________________________________________________________
Other: ___________________________________________________________
Release of Information: I hereby authorize _______________ to release the medical information contained on
(Doctor’s name)
this form, to the _________________________for the purposes of determining my physical health.
(County/Agency)
Patient Signature
Date
I. Medical History:
(check any that apply and provide comment):
Heart Disease
Impaired Sight
Orthopedic Problems
Cancer
Heredity Conditions
Chronic Medical Conditions
Diabetes
Hypertension
Mental Illness
Impaired Hearing
Allergies
Respiratory Condition
Seizure Disorder
TB screen
test
neg
positive
xray
Other-
Comment: ________________________________________________________________________________
Tobacco Usage
Do you smoke nicotine cigarettes? __________ If so, how many packs per day? __________
Alcohol Consumption
How many alcoholic beverages do you consume daily? ______________________________________________
Limits or restrictions on physical activity: ______________________________________________________
HEALTH SCREENING
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