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This document is a screening form for H1N1 Influenza A, used to collect symptomatic information for testing of suspected cases in the Grand Forks area, particularly focusing on patients with fever
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How to fill out suspect h1n1 influenza a
How to fill out SUSPECT H1N1 INFLUENZA A (Swine Flu) SCREENING FORM
01
Begin by obtaining the SUSPECT H1N1 INFLUENZA A SCREENING FORM from your healthcare provider or relevant authority.
02
Fill out the patient's personal information, including their full name, date of birth, and contact details.
03
Indicate the reason for screening - whether the patient is exhibiting symptoms typical of H1N1.
04
Check the box if the patient has been in contact with a confirmed case of H1N1.
05
Describe any symptoms the patient is experiencing, such as fever, cough, or body aches.
06
Provide information on recent travel history, especially to areas with known H1N1 outbreaks.
07
Review the completed form for any missing information before submission.
08
Submit the form to the designated healthcare professional or location for evaluation.
Who needs SUSPECT H1N1 INFLUENZA A (Swine Flu) SCREENING FORM?
01
Individuals who are exhibiting flu-like symptoms and have potential exposure to H1N1.
02
Persons who have been in contact with confirmed H1N1 cases.
03
Individuals who have recently traveled to regions with reported H1N1 outbreaks.
04
Patients seeking assessment for appropriate care and potential testing for H1N1.
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What is SUSPECT H1N1 INFLUENZA A (Swine Flu) SCREENING FORM?
The SUSPECT H1N1 INFLUENZA A (Swine Flu) SCREENING FORM is a document used to identify and assess individuals who may have symptoms related to H1N1 influenza. It helps healthcare providers determine if further testing or treatment is necessary.
Who is required to file SUSPECT H1N1 INFLUENZA A (Swine Flu) SCREENING FORM?
Individuals exhibiting symptoms of H1N1 influenza, as well as healthcare providers who assess such individuals, are required to file the SUSPECT H1N1 INFLUENZA A SCREENING FORM.
How to fill out SUSPECT H1N1 INFLUENZA A (Swine Flu) SCREENING FORM?
To fill out the SUSPECT H1N1 INFLUENZA A SCREENING FORM, individuals must provide personal information including name, contact details, symptoms experienced, travel history, and exposure history to confirmed cases.
What is the purpose of SUSPECT H1N1 INFLUENZA A (Swine Flu) SCREENING FORM?
The purpose of the SUSPECT H1N1 INFLUENZA A SCREENING FORM is to facilitate the early identification of possible H1N1 cases, ensuring timely medical intervention and preventing the spread of the virus.
What information must be reported on SUSPECT H1N1 INFLUENZA A (Swine Flu) SCREENING FORM?
The information that must be reported includes personal details (name, age, contact information), symptoms (fever, cough, sore throat, etc.), travel history, contact with infected individuals, and any previous vaccinations against H1N1.
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