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 Spanish

Cuestionario de contraindicaciones para la vacuna inyectable contra la gripe (Screening Checklist for Contraindications to Inactivated Injectable Influenza Vaccination)

Nombre del Paciente (Patient Name) *

Nombre y Apellido

Fecha de Nacimento del Paciente (Patient Date of Birth) *

Para pacientes adultos y para los padres de niños a los que se van a vacunar: (For patients (both children and adults) to be vaccinated:)

Las siguientes preguntas nos ayudarán a determinar si hay algún motivo por el cual no deberíamos aplicar hoy la vacuna inyectable contra la influenza (la gripe) a usted o a su hijo. Si contesta ?sí? a alguna de las preguntas, eso no siempre quiere decir que usted (o su hijo) no se debe vacunar. Simplemente quiere decir que hay que hacerles más preguntas. Si alguna pregunta no está clara, pida a su profesional de la salud que se la explique. (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. La persona que se va a vacunar, ¿está enferma hoy? (1. Is the person to be vaccinated sick today?) *

2. La persona que se va a vacunar, ¿es alérgica a algún componente de la vacuna? (2. Does the person to be vaccinated have an allergy to a component of the vaccine?) *

3. La persona que se va a vacunar, ¿tuvo alguna vez una reacción seria a la vacuna contra la influenza (gripe)? (3. Has the person to be vaccinated ever had a serious reaction to influenza vaccine in the past?) *

4. La persona que se va a vacunar, ¿tuvo alguna vez el síndrome de Guillain-Barré? (4. Has the person to be vaccinated ever had Guillain-Barré syndrome?) *

Nombre del Padre y Tutor (Form Completed By) *

First & Last Name

Fech (Today's Date) *

Este cuestionario es una adaptación del Cuestionario sobre la influenza de IAC. El original se puede encontrar en www.immunize.org/catg.d/p4066.pdf ? Item #P4066 (9/19) 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