M.T. Curry Inc - Publicforms

Available Forms

12 Month Wellness Exam 12 Month Wellness Exam Spanish 18 Month Wellness Exam 18 Month Wellness Exam Spanish 24 Month Wellness Exam 24 Month Wellness Exam Spanish 3-21 Year Wellness Exam 3-21 Year Wellness Exam Spanish ACT 12 years and older ACT 12 years and older Spanish ACT 4 to 11 years ACT 4 to 11 years Spanish ADHD Agreement ADHD Agreement Spanish Adult ADHD Self-Report Scale Adult ADHD Self-Report Scale Spanish Conner's Pediatric Conner's Pediatric Spanish COVID-19 Screening English COVID-19 Screening Spanish 2 Family Medical History Family Medical History Spanish Flu Quest 2020 Flu Quest 2020 Spanish HIPAA 18yr HIPAA 18yr Spanish Interview & Lunch Rep COVID-19 Screening New Patient Registration New Patient Registration Spanish Newborn Insurance Waiver Newborn Insurance Waiver Spanish PHQ-9 and GAD (Patient Health Questionnaire and General Anxiety Disorder) PHQ-9 (Patient Health Questionnaire) PHQ-9 (Patient Health Questionnaire) Spanish Records Request Personal Use Records Request Personal Use Spanish Records Request Prior Doctor Records Request Prior Doctor Spanish Self Pay Waiver Self Pay Waiver Spanish Telehealth Agreement Update Demographics Returned Mail Vanderbilt - Parent Well Child Waiver Well Child Waiver Spanish

Flu Quest 2020

Screening Checklist for Contraindications to Inactivated Injectable Influenza Vaccination

Patient Name *

First & Last Name

Patient Date of Birth *

For patients (both children and adults) to be vaccinated:

The following questions will help us determine if there is any reason we should not give you or your child inactivated injectable influenza vaccination today. If you answer ?yes? to any question, it does not necessarily mean you (or your child) should not be vaccinated. It just means additional questions must be asked. If a question is not clear, please ask your healthcare provider to explain it.

1. Is the person to be vaccinated sick today? *

2. Does the person to be vaccinated have an allergy to a component of the vaccine? *

3. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past? *

4. Has the person to be vaccinated ever had Guillain-Barré syndrome? *

Form Completed By *

First & Last Name

Today's Date *

This questionnaire is an adaptation of the IAC Flu Questionnaire. The original can be found at www.immunize.org/catg.d/p4066.pdf ? Item #P4066 (9/19)

* Required field