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Physical Examination for Admission to Portage Manor Licensed Residential Care Facility

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  2. Physical Examination for Admission to Portage Manor Licensed Residential Care Facility
  3. Physical examination will be needed by a licensed physician after the applicatant has been accepted for admissions.
  4. Please read Mantoux in millimeters at 72hrs; required within 3 months of admission.
  5. Chest X-Ray must be done within 6 months prior to admission if Mantoux is positive and/or contraindicated.
  6. Free of Tuberculosis:
  7. Free of Communicable Disease at time of exam:
  8. Diagnosis:
  9. General Exam
  10. *All areas of the form must be completed and signed by physician for Admission
  11. Leave This Blank:

  12. This field is not part of the form submission.