Get the free MELIOIDOSIS INTAKE FORM - publichealth lacounty

MELIOIDOSIS INTAKE FORM Acute Communicable Disease Control 313 N. Figueroa St., Rm. 212, Los Angeles, CA 90012 213-240-7941 (phone) 213-482-4856 (facsimile) www.publichealth.lacounty.gov/acd VCR ID:

How to fill out melioidosis intake form

How to fill out a melioidosis intake form:

1. Start by carefully reading the form instructions and ensure you understand the purpose and required information for the melioidosis intake form.
2. Begin by providing your personal details, such as your full name, date of birth, contact information, and address. This information is essential for identification and follow-up purposes.
3. Move on to the medical history section where you will be asked to disclose any relevant medical conditions, previous illnesses, surgeries, or allergies. Be honest and provide as much detail as possible to help the healthcare provider evaluate your risks and potential complications.
4. Proceed to answer questions about your recent travel history, especially if you have been to areas where melioidosis is prevalent. Include information about the countries you visited, duration of stay, and any activities that may have exposed you to the bacteria.
5. If you have been in direct contact with a person known to have melioidosis, make sure to indicate this in the form. This includes close contact, sharing personal items, or living in the same household as an infected individual.
6. You may be asked about your occupation, as certain professions that involve working outdoors or in high-risk environments can increase the likelihood of melioidosis exposure. Provide accurate information about your work environment and any potential occupational hazards.
7. The healthcare provider might inquire about any recent injuries or wounds that could potentially be sites for melioidosis infection. Be prepared to give details about the nature of the injury, how it occurred, and any treatment received.
8. Finally, ensure that you review all your answers before submitting the form. Double-check for any errors or missing information that could affect the accuracy of your evaluation.

Who needs a melioidosis intake form?

1. Individuals who are experiencing symptoms suggestive of melioidosis, such as high fever, respiratory problems, muscle aches, or skin infections, may need to fill out a melioidosis intake form.
2. People with a recent travel history to regions or countries where melioidosis is prevalent, such as Southeast Asia, Northern Australia, or parts of South America, may be required to complete the melioidosis intake form to assess their potential exposure risk.
3. Healthcare professionals who suspect a patient might have melioidosis based on their symptoms, occupation, or travel history may use the melioidosis intake form to gather relevant information for diagnostic and treatment purposes.

In summary, filling out the melioidosis intake form involves providing personal details, disclosing medical history, answering questions about travel and contact history, and listing any potential exposures or risk factors. The form is necessary for evaluating melioidosis risks and initiating appropriate medical interventions.

For pdfFiller’s FAQs

What is melioidosis intake form?

Melioidosis intake form is a document used to collect information about individuals who are suspected or confirmed to have melioidosis.

Who is required to file melioidosis intake form?

Healthcare professionals, laboratories, and public health agencies are required to file melioidosis intake form.

How to fill out melioidosis intake form?

The melioidosis intake form should be filled out with accurate information about the patient's demographics, symptoms, medical history, and any known exposure to Burkholderia pseudomallei.

What is the purpose of melioidosis intake form?

The purpose of the melioidosis intake form is to gather data to help with the diagnosis, treatment, and prevention of melioidosis.

What information must be reported on melioidosis intake form?

Information such as patient's name, age, address, symptoms, medical history, and any potential exposure to Burkholderia pseudomallei must be reported on the melioidosis intake form.

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