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2. 
3. Physical Examination for Admission to Portage Manor Licensed Residential Care Facility
5. Physical examination will be needed by a licensed physician after the applicatant has been accepted for admissions.
7. Applicant's Name:*
8. D.O.B.*
9. Phone #:
11. Address
13. City
14. State
15. Zip Code
19. Physician's Name:
20. Date:
    Date:
22. Address
24. City
25. State
26. Zip Code
29. Blood Pressure:
30. Pulse:
33. Respiration:
34. Temperature:
37. Height:
38. Weight:
40. Mantoux Date Given:
41. Mantoux Date Read:
42. Result:
44. Given By:
45. Read By:
47. Please read Mantoux in millimeters at 72hrs; required within 3 months of admission.
51. Chest X-Ray must be done within 6 months prior to admission if Mantoux is positive and/or contraindicated.
53. Chest X-Ray Date:
54. Written Results:
55. Copy Attached:
57. Free of Tuberculosis:

    1. YES
    2. NO
58. Free of Communicable Disease at time of exam:

    1. YES
    2. NO
60. Diagnosis:
62. Allergies:
63. Diet:
64. Activity Order:
68. General Exam
71. Head:
72. Eyes:
75. Ears:
76. Nose:
79. Neck:
80. Lungs
83. Heart:
84. Throat:
87. Abdomen:
88. Back:
91. Genitals:
92. Rectal:
95. Skin:
96. Neurologic:
98. Medication Orders:
99. May use generic:
101. *All areas of the form must be completed and signed by physician for Admission
103. Physician Signature:
104. Date
     Date
Leave This Blank:


106. 1. Receive an email copy of this form.
107. Email address

     This field is not part of the form submission.

108. Submit Submit and Print

* indicates a required field