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TFORD, CT 06134 0308 ALIEN #: VOICE: (860) 509 7722 FAX: DATE OF HEALTH ASSESSMENT: (860) 509 7743 PATIENT'S NAME: LAST, FIRST, MIDDLE MM DATE OF BIRTH: M STREET ADDRESS: CITY: RACE (PLEASE CHECK ALL THAT APPLY): ETHNIC ORIGIN: HISPANIC NON HISPANIC AMERICAN INDIAN/ALASKA NATIVE STATE: DD YYYY MM DD HOME TELEPHONE: SEX: YYYY F ZIP: COUNTRY OF BIRTH: U.S. ENTRY DATE: MM DD YYYY OVERSEAS TB CLASS A, B1, OR B2 STATUS? (REVIEW OVERSEAS DOCUMENTS) ASIAN BLACK OR AFRICAN.

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Follow the steps to complete your Xvideospdf online

  1. Select the ‘Get Form’ button to access the Xvideospdf and enable the online editor for filling out the form.
  2. Start by entering the patient's name, including last, first, and middle. This information is critical for identifying the individual receiving the health assessment.
  3. Record the date of birth using the provided format (MM/DD/YYYY), ensuring all necessary parts are filled accurately.
  4. Input the patient's street address, city, state, and ZIP code to indicate their current residence.
  5. Check all applicable race boxes and indicate the patient's ethnic origin (Hispanic or non-Hispanic).
  6. Provide information on the country's birth and the date of entry into the U.S. using the MM/DD/YYYY format.
  7. Indicate if language interpretation is needed, and specify the preferred language for communication.
  8. Review all relevant immunization documents and fill in the immunization sections as required, making sure to indicate immunity status.
  9. Complete tuberculosis screening details by reviewing tests done within the U.S., including any necessary follow-up actions.
  10. Fill out sections on hepatitis B and C screening, ensuring all results are appropriately noted.
  11. Record any additional laboratory tests or screenings conducted, including special considerations for mental health screening.
  12. Conclude by providing your name and contact details in the physician's section and be sure to attach any necessary referrals or comments.
  13. Once all sections are completed, save the changes. You can then download, print, or share your form as needed.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Your Privacy Choices
Terms of Service
Privacy Notice
Legal Hub
Content Takedown Policy
Bug Bounty Program
About Us
Help Portal
Legal Resources
Blog
Affiliates
Contact Us
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
altaFlow
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232