Form Rfa 07 - Health Screening For County/agency Page 2

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III. Medications
(Please list all medications the patient is currently taking including medical marijuana.
Additional medications can be listed in an attachment.)
Name of Medication
Dose and Condition Prescribed For:
IV. Additional Comments by Licensed Health Professional
(Please note any health condition that may create a risk to the health or safety of the patient, children, or others in
the patient’s care)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
V. Certification
I certify that I completed the health screening on this patient for the purpose of verifying the patient’s
physical health.
Date Examined
Signature of Licensed Health Professional
Telephone Number
Printed Name of Licensed Health Professional
Address of Licensed Health Professional
Reminder to Applicant:
Please return the completed RFA Health Screening to your assigned
RF worker.
HEALTH SCREENING

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