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Attachment TELEHEALTH OREGON REGION MEDICAL STAFF SERVICES IMMUNE HISTORY QUESTIONNAIRE Immunity & Testing TB Test (results must be included with this form) TB CXR (if positive TB Test) Varicella
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01
Read and understand the instructions on the immune hx questionnaire.doc form.
02
Start by providing your personal information such as name, date of birth, and contact details.
03
Follow the prompts and checkboxes on the form to indicate your medical history and any previous immunizations received.
04
If you are unsure about any specific question, consult with your healthcare provider for guidance.
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Submit the completed immune hx questionnaire.doc to the designated recipient or healthcare provider as instructed.
Who needs immune hx questionnairedoc?
01
Individuals undergoing medical check-ups or assessments that require an evaluation of their immune history.
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Patients who are considering or in need of specific immunizations.
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Healthcare professionals responsible for monitoring or managing patients' immunization records.
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Researchers or organizations conducting studies on immune-related topics that require participant information.
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