PHYSICIAN EXAMINATION

Applicant's Name

First NameMiddle NameLast Name
Diocese of San Bernardino
HEALTH FORM

CONFIDENTIAL
NOTICE TO EXAMINING PHYSICIAN

The above-named individual is applying for admission to a program of Priestly Formation in the Roman Catholic Bishop of San Bernardino. Part of the application process includes a through physical examination. Church law requires that applicants must have a good health which will enable them to undergo the rigors of the seminary as well as the life-long obligations of the priesthood. We rely on your professional expertise to assist us to determine that this applicant is in good health. Thank you.

PHYSICIAN: Please return completed form to:

Vocations Office

Address: 12716 Oriole Ave. Grand Terrace, CA 92313

NOTE: This information is striclty for the use of the Diocese of San Bernardino and will not be released to anyone else without the knowledge or consent of the applicant.
PHYSICIAN EXAMINATION
Applicant's Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
PHYSICIAN'S REPORT OF HEALTH EVALUATION

EXAMINING PHYSICIAN: Please review the applicant's history and complete this section of the report. This information is strictly for the use of the Diocese of San Bernardino and will not be released without the applicant's consent.

	Results
Blood Pressure
Pulse Rate
Temperature
Respiration / Respiratory Rate

	Please fill out if there is any abnormal conditions
Head and Neck:
Chest/Lungs:
Heart:
Abdomen:
Genitalia:
Ano-Rectal & Prostate:
Musculo-Skeletal:
Neurological:
Skin:

REQUIRED LABORATORY: CBC, Urinalysis, Fasting Chemistry 24, Serology, TB Test, HIV antibody (AIDS test For patients over 35 years of age, Chest X-ray and EKG are also required.

NOTE: The above required laboratory studies are in addition to any studies indicated by the History and Physical Examination.

Tests:

Copies of all laboratory reports are to be included with this completed medical statement.

Cancelof
Recommendations for physical activity:

UnlimitedLimited
If limited, please explain:
Do you have any recommendations regarding the care of this patient?

YesNo
Recommendations:
Is applicant now under treatment for any medical or emotional condition?

YesNo
If yes, please explain:
Physician's Signature
Date

MonthDayYear
Physician's Name:

First NameMiddle NameLast Name
Address

Address

Street Address Line 2

City State ZipState / Province

Postal / Zip Code
FOR APPLICANT USE:

PLEASE SIGN THE FOLLOWING RELEASE:

I grant permission to the Vocations Director of the Diocese of San Bernardino, and Rector of St. Junipero Serra House of Formation to speak with my doctor regarding my medical condition and so that any additional statements and interpretation of my medical condition might be ascertained as they pertain to my ability to undergo serious graduate studies.
Applicant's Name

First NameMiddle NameLast Name
Signature

Clear
Date

MonthDayYear
Should be Empty:

Diocese of San Bernardino