WELL GIVEN AFC, INC.

30 Eastbrook Rd., suite#404, Dedham, MA 02026

Tel: (781) 320-0855
Fax: (617) 206-3195

☐ This is to certify that ________________________________________________, DOB: ____________

has been examined on _______________________ and is found to be physically fit and able

to work for Adult Foster Care program. No Restrictions to work.

☐ The test for tuberculosis has been administrated to the above named patient,

and the results have been found to be ___________________ on ___________________________.

(date result read)

☐ The person listed above is tuberculin positive.

A chest x-ray was done on ___________________________________________.

This person (listed above) _____ does not exhibit or _____ exhibit symptoms
(please check one)
consistent with pulmonary tuberculosis such as: (please checkmark whatever applies):
• Cough lasting longer than three (3) weeks;
▪ Unexplained fever;
• Night sweats;
• Unexpected weight loss;
• Coughing up blood;
• Chest pain

If none of these symptoms are present, a chest x-ray is NOT NECESSARY.

If symptoms consistent with pulmonary tuberculosis such as those listed

above develop, seek immediate medical help.

___________________________________________MD/NP/PA
Physician Signature

______________________________________________
Print Name

Person to contact if we have questions regarding this medical form:

Name:__________________________________________________ Phone:__________________________

Revised 07.01.14