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C.H.M.C INFLUENZA VACCINATION QUESTIONNAIRE & CONSENT FORM 2019 Name: D.O.B: / / Age: Employer: Home Address: BACKGROUND: The influenza virus can cause major epidemics of respiratory disease. The
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How to fill out chmc influenza pre-vaccination questionaire
How to fill out chmc influenza pre-vaccination questionaire
01
To fill out the CHMC influenza pre-vaccination questionnaire, follow these steps:
02
Obtain the questionnaire form from a healthcare provider or download it from the CHMC website.
03
Fill in your personal information, including your name, date of birth, and contact details.
04
Answer the questions regarding your medical history, including any allergies or previous adverse reactions to vaccines.
05
Provide information about any current medications you are taking, as well as any recent illnesses or surgeries.
06
Answer the questions related to your exposure to influenza and any symptoms you may be experiencing.
07
Sign and date the questionnaire to certify that the information provided is accurate.
08
Return the completed questionnaire to your healthcare provider or the designated submission location.
Who needs chmc influenza pre-vaccination questionaire?
01
The CHMC influenza pre-vaccination questionnaire is needed by individuals who intend to receive the influenza vaccine. It helps healthcare providers assess the patient's eligibility for vaccination and identify any potential contraindications or precautions.
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