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ADULT PERTUSSIS SCREENING FORM It is important to evaluate your risk of contracting pertussis, commonly known as whooping cough. Adults can contract this disease and potentially pass it on to infants

How to fill out adult pertussis screening form

How to Fill Out Adult Pertussis Screening Form:

1. Start by carefully reading the instructions on the form. It is important to understand the purpose of the screening and the information required.
2. Provide your personal details such as your name, date of birth, and contact information. Make sure to write legibly and accurately.
3. Answer the questions on the form honestly and to the best of your knowledge. These questions may include inquiries about your medical history, recent symptoms, and any known exposure to individuals with pertussis (also known as whooping cough).
4. If you are unsure about any specific question, it is recommended to seek clarification from a healthcare professional or the administrator of the screening form.
5. Fill out any additional sections or fields that are relevant to your situation. This may include providing information about your vaccination history or any medications you are currently taking.
6. Review your completed form to ensure that all sections have been appropriately filled out. Double-check for any errors or missing information.
7. Once you are confident that the form is complete, sign and date it as required. This verifies that the information provided is accurate to the best of your knowledge.
8. Submit the form to the designated recipient or follow the instructions provided for its submission. This may involve mailing it to a specific address, handing it in at a healthcare facility, or submitting it online.
9. Keep a copy of the completed form for your records. It can serve as documentation of your screening and may be useful for future reference.

Who Needs Adult Pertussis Screening Form:

1. Adults who are experiencing symptoms of pertussis, such as severe coughing fits, whooping sound while breathing in after coughing, or vomiting after coughing.
2. Individuals who have been in close contact with someone diagnosed with pertussis, especially if they have had prolonged exposure or shared living spaces.
3. Healthcare workers, particularly those who work with vulnerable populations, as they may be at a higher risk of exposure to pertussis and need to ensure they are not a carrier of the infection.
4. Pregnant women, as pertussis can lead to severe complications for both the mother and baby. Screening helps determine if the mother requires treatment or vaccination to protect herself and her child.
5. Individuals planning to travel to areas with ongoing pertussis outbreaks or regions with a higher incidence of the disease. This precaution helps prevent the introduction and spread of pertussis in different locations.
6. Anyone seeking to participate in certain activities or events that require proof of pertussis screening, such as joining a healthcare training program or working in childcare facilities.

It is important to note that the specific requirements for pertussis screening may vary based on regional guidelines, healthcare provider recommendations, and individual circumstances. Therefore, it is always best to consult with a healthcare professional to determine if you need to fill out an adult pertussis screening form.

For pdfFiller’s FAQs

What is adult pertussis screening form?

The adult pertussis screening form is a document used to assess the risk of pertussis (whooping cough) in adults.

Who is required to file adult pertussis screening form?

Adults who may have been exposed to pertussis or who exhibit symptoms of the disease are required to file the form.

How to fill out adult pertussis screening form?

The form must be completed by providing personal information, symptoms experienced, exposure history, and relevant medical history.

What is the purpose of adult pertussis screening form?

The purpose of the form is to help healthcare providers determine if an individual should be tested for pertussis and receive treatment if necessary.

What information must be reported on adult pertussis screening form?

Information such as personal details, symptoms, exposure history, and medical history must be reported on the form.

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