Form Mc 223c - Supplemental Statement Of Facts For Medi-Cal Child Only - Under Age 18 (Chinese) Page 8

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State of California—Health and Human Services Agency
Department of Health Care Services
第7部分——測試
County Use Only
該兒童是否曾經，或他/她是否將會接受任何病、傷或健康問題的醫療測試？
(MC 220) signed
是
如果是，說明以下資訊：
否
曾經/未來的測試時間？
測試地點？
測試類型
誰讓孩子進行的測試？
（月，年）
（測試點名稱）
EKG
（心臟測試）
Treadmill
（運動測試）
Cardiac
Catheterization
Biopsy
(Name of Body Part)
Speech/Language
Hearing Test
Vision Test
IQ Test
EEG
（腦電波測試）
HIV Test
Blood Test
(Not HIV)
Breathing Test
X-Ray
(Name of Body Part)
MRI/CAT Scan
(Name of Body Part)
如果該兒童進行過其他測試，請在第9部分（評論）中列出
第8部分——工作經歷
(MC 220) signed
孩子是否有過工作經歷？
是
如果是，請填寫以下資料：
否
工作日期
雇主姓名
地址（街道、門牌號）
城市
州
郵編
電話號碼
主管姓名
MC 223C_CHI_0611
第8頁，共9頁

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