GRADUATE MEDICAL EDUCATION _KFH SAN FRANCISCO

2425 Geary Blvd., San Francisco, CA 94115

Phone: 415-833-3034 Fax: 415-833-4983

STATEMENT OF PHYSICAL HEALTH

A skin test has been performed for TUBERCULOSIS with the following results:

__________ Skin Test NEGATIVE Date Done: ________________________

__________ Skin Test POSITIVE (a CXR must be done)

__________ CXR NEGATIVE ___________ Date __________ CXR POSITIVE

Titers Results Date Immunization Given (Date)

Rubella _____________________ ___________________ _______________________

Rubeola (Measles) _____________________ ___________________ _______________________

Mumps _____________________ ___________________ _______________________

Varicella _____________________ ___________________ _______________________

Hep B surface antibody _____________________ ___________________ _______________________

Hep B Declination Date _____________________

Exceptions (if any): _________________________________________________________

__________________________________ ________________ _________________________________

Signature Date Print Name and Title

The above certificate must be satisfactorily completed by your personal Physician or Student Health Service,

and accompany your application.