Get the free Pertussis Assessment Form for Clinicians

Pertussis Assessment Form In lieu of a Confidential Morbidity Report, please complete this form when you have a patient with possible pertussis. Have the form completed by staff. Public Health is

How to fill out pertussis assessment form for

How to fill out pertussis assessment form for

1. Start by gathering the necessary information for the pertussis assessment form, including the patient's personal details, medical history, and symptoms.
2. Begin filling out the form by entering the patient's full name, date of birth, and contact information.
3. Provide the patient's medical history, including any previous diagnoses or treatments for pertussis or related conditions.
4. Document the patient's symptoms, such as persistent cough, runny nose, and difficulty breathing. Include the date of onset for each symptom.
5. Include information about any recent exposure to pertussis or individuals diagnosed with pertussis.
6. If applicable, document any laboratory test results or diagnostic procedures that have been conducted for the patient.
7. Include any additional relevant information or observations that may assist in the assessment and diagnosis of pertussis.
8. Review the completed form for accuracy and completeness before submitting it.
9. Submit the pertussis assessment form to the appropriate healthcare provider or public health department, as instructed.

Who needs pertussis assessment form for?

1. The pertussis assessment form is necessary for individuals suspected or confirmed to have pertussis, also known as whooping cough.
2. This form is typically required by healthcare providers, public health departments, and other organizations involved in monitoring and managing pertussis cases.
3. It helps in documenting and assessing the symptoms, medical history, and potential exposure to pertussis, aiding in the diagnosis and appropriate management of the disease.

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What is pertussis assessment form for?

The pertussis assessment form is used to assess the risk of pertussis infection in individuals.

Who is required to file pertussis assessment form for?

Healthcare providers and facilities are required to file pertussis assessment forms for their patients.

How to fill out pertussis assessment form for?

The pertussis assessment form should be filled out by providing relevant information about the patient's symptoms, medical history, and potential exposure to pertussis.

What is the purpose of pertussis assessment form for?

The purpose of the pertussis assessment form is to evaluate the likelihood of a pertussis infection in individuals and to facilitate appropriate medical care.

What information must be reported on pertussis assessment form for?

Information such as patient demographics, symptoms, medical history, and exposure to pertussis must be reported on the pertussis assessment form.