To be filled out by applicant's physician. Please type or print clearly.
 
 

Applicant's Name: ____________________________________________________

Address:___________________________________________________

Have you been the applicant's regular physician? Yes_________ No________

If so, how long? ___________________
 
 

GENERAL INFORMATION
 

General Appearance ___________________________________________________
 

Explain any physical abnormalities ________________________________________

____________________________________________________________________
 
 

PAST HISTORY

Past Hospitalizations (including surgeries): _________________________________

____________________________________________________________________
 

History of drug abuse:___________________________________________________

History of alcohol abuse: ________________________________________________

Significant past illness: __________________________________________________
 
 

FAMILY HISTORY (signficant medical/psychiatric):_______________________

_____________________________________________________________________

_____________________________________________________________________
 
 

CURRENT INFORMATION

Medicines (including recurrent non-prescriptives):_____________________________

_____________________________________________________________________

Significant present medical problems:_______________________________________

_____________________________________________________________________

Allergies: _____________________________________________________________

Dietary Restrictions: ____________________________________________________

Tobacco/alcohol use:____________________________________________________

Physical restrictions:_____________________________________________________
 
 
 
 
 
 

GENERAL PHYSICAL
 

Wt. ______________ Ht.______________ B.P. ______________ P. ____________

Lab (if done recently): U/A____________ CXR ___________ CBC_____________

Manu____________
 

Note - for normal + for abnormal
 

General appearance ____________ Eyes ____________ Ears ____________ Nose_______

Mouth ___________ Adenopathy ___________ Chest __________ Breast _____________

Heart __________ Abdomen ___________ Genitals ____________ Rectum ____________

Skin __________ Neurological ___________ Medical status exam ____________________
 
 

Please note any abnormalities noted above________________________________________

__________________________________________________________________________

__________________________________________________________________________
 
 
 
 

I recommend this patient to live in community and work for the The Little Sisters of the Assumption in their social service programs.
 

YES_______________________ NO__________________
 

Physician _________________________________ Date____________________
 

*Printed name and address of Physician's office_______________________________________

____________________________________________________________________________

*Physician's Phone_______________________
 

* must be filled out for verification purposes
 

Please return form to:

Coordinator of LSAV
417 East 115th Street
New York, NY 10035