School health examination form
[PDF File]SC-104 Clerk stamps date here when form is filed. Proof of ...
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SC-104 Proof of Service • Owner (for a sole proprietorship) b. If you are serving a business or entity, write the name of the business or entity, the person authorized for service, and that person’s job title: 2 Judicial Council of California, www.courtinfo.ca.gov SC-104, Page 1 of 2 Revised January 1, 2009, Optional Form
[PDF File]VAMC SLUMS Examination - School of Medicine
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SH Tariq, N Tumosa, JT Chibnall, HM Perry III, and JE Morley. The Saint Louis University Mental Status (SLUMS) Examination for Detecting Mild Cognitive Impairment and Dementia is more sensitive than the Mini-Mental Status Examination (MMSE) - A pilot study. J am Geriatri Psych ( in press). 2 3 Questions about this assessment tool? E-mail aging ...
[PDF File]Form W-9 (Rev. October 2018)
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• Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See . What is backup withholding, later.
[PDF File]MEDICAL REQUEST FOR HOME CARE HCSP- M11Q …
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PATIENT'S MEDICAL RELEASE: I hereby authorize all physicians and medical providers to release any information acquired in the course of my examination of treatment to the New York City HRA/ Dept. of Social Services in connection with my request for home care.
[PDF File]Edinburgh Postnatal Depression Scale (EPDS)
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Edinburgh Postnatal Depression Scale 1 (EPDS) Postpartum depression is the most common complication of childbearing. 2 The 10-question Edinburgh
[PDF File]I am authorized by law to examine you for the purpose of ...
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2. I certify that on this date I read the above statement to the individual before asking any questions or conducting any examination. 3. I further certify that I, Name (type or print), personally examined Patient at Name and address where examination took place on Date starting at Time and continuing for minutes.
[PDF File]TINETTI BALANCE ASSESSMENT TOOL
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TINETTI BALANCE ASSESSMENT TOOL GAIT SECTION Patient stands with therapist, walks across room (+/- aids), first at usual pace, then at rapid pace. Risk Indicators: Tinetti Tool Score Risk of Falls ≤18 High 19-23 Moderate ≥24 Low Date Indication of gait (Immediately after told to ‘go’.) Any hesitancy or multiple attempts = 0 No hesitancy = 1
[PDF File]Patient Health Questionnaire (PHQ-9)
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PATIENT HEALTH QUESTIONNAIRE (PHQ-9) NAME: DATE: Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all Several days More than half the days Nearly every day (use " ü " to indicate your answer) 1. Little interest or pleasure in doing things 0 1 2 3
[PDF File]Form 1040X Amended U.S. Individual Income Tax Return
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Form 1040X (Rev. January 2019) ... Full-year health care coverage (or, for 2018 amended returns only, exempt). See inst. Use Part III on the back to explain any changes. A. Original amount. reported or as ... Enter the result here and on line 4a on page 1 of this form. If
[PDF File]Request for Leave or Approved Absence
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a serious health condition may be required by your agency. I hereby invoke my entitlement to Family ... including medical/dental/optical examination of family member, or bereavement: Care of family member with a serious health condition ... If your agency uses the information furnished on this form for purposes other than those indicated above ...
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