Get the free CHWS Medical History and Immunization Form - pugetsound

1555 Fax 253. 879. 3766 E-mail chws ups. edu CHWS MEDICAL HISTORY AND IMMUNIZATION FORM Name Last First DOB Mo-Day-Yr MI SS Date form completed UPS ID Permanent Address Street City Gender F State Person to be notified in case of emergency Name ZIP M T Phone Relationship Will you be covered by Health Insurance while attending Puget Sound Yes No Will your Insurance cover you in Washington State Yes No Name of Medical Insurance Company ID Group Medi...

How to fill out chws medical history and

How to fill out CHWS Medical History and Immunization Form

1. Begin with personal information: Fill in your name, date of birth, and contact information.
2. Complete demographic details: Provide information about your gender, ethnicity, and insurance coverage.
3. Medical history section: List any past medical conditions, surgeries, and hospitalizations.
4. Family medical history: Indicate any relevant health issues in immediate family members.
5. Current medications: Include all medications you are currently taking, along with dosages.
6. Allergies: Specify any known allergies to medications, foods, or environmental factors.
7. Immunization history: Record vaccinations received, including dates and any boosters.
8. Review your entries for accuracy before submitting the form.

Who needs CHWS Medical History and Immunization Form?

1. Individuals seeking healthcare services from CHWS.
2. Parents or guardians filling the form for minors.
3. Anyone who requires an updated medical history for vaccinations.

People Also Ask about

Who can fill out my immunization form?

Students should complete the AAMC Standardized Immunization Form in conjunction with either the student health office at their medical school or with their primary care provider.

Does New York have religious exemption for vaccines?

Parents can ask for a medical exemption if a vaccine wouldn't be safe for their child. Reasons that children can get an exemption include: They have a disease or take medicine that weakens their immune system. They have a severe allergy to a vaccine or an ingredient in it.

What qualifies for a medical exemption for vaccines?

DECLINE: I do not want the flu vaccination given to me because of a sincerely held religious reason. I realize that my refusal may put patients, visitors, and family at risk. By declining the influenza vaccine, I understand I am at risk of acquiring influenza.

How to decline the flu shot for religious reasons?

In order to request a religious exception, please fill out this form. The agency may ask for other information as needed to determine if you are legally entitled to an exception. Signing this form constitutes a declaration that the information you provide is, to the best of your knowledge and ability, true and correct.

What states do not allow religious exemptions for vaccines?

All states allow exemptions for medical reasons, and almost all states (except California, Mississippi and West Virginia) grant religious or philosophical exemptions for people who have sincerely held beliefs that prohibit immunizations.

For pdfFiller’s FAQs

What is CHWS Medical History and Immunization Form?

The CHWS Medical History and Immunization Form is a document used to collect an individual's medical background and vaccination records.

Who is required to file CHWS Medical History and Immunization Form?

Individuals who are enrolled in certain health programs or schools may be required to file the CHWS Medical History and Immunization Form.

How to fill out CHWS Medical History and Immunization Form?

To fill out the CHWS Medical History and Immunization Form, individuals should provide accurate personal information, list any medical conditions, and document all vaccinations received.

What is the purpose of CHWS Medical History and Immunization Form?

The purpose of the CHWS Medical History and Immunization Form is to ensure that health providers have complete information about an individual's health history and vaccination status.

What information must be reported on CHWS Medical History and Immunization Form?

The information that must be reported includes personal identification details, medical history, current medications, allergies, and a record of immunizations.