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About
Services
Home Care
Companion Care
Enhanced Pediatric Care
Personal Care & Support
Home Infusion – IV Therapy
Blog
Service Areas
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Forms
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Schedule Appointment
Varicella Questionnaire
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This questionnaire is a RIGHTCARE HOME HEALTH SERVICES, LLC Employment Requirement designed to determine your history of Varicella a.k.a. chickenpox. Please complete all the following questions to the best of your knowledge.
It is recommended that the healthcare workers, teachers of the young, daycare workers, college students, those who travel internationally, confined to intuitional settings or in the military obtain the vaccine which was introduced in 1995.
Chickenpox is an infectious disease caused by the varicella, a virus of the herpes family. The Transmission is spread by coughing, sneezing, direct contact and considered highly contagious. An individual is contagious for 1-2 days followed by 10-21 days before symptoms appear. Individuals who may not be able to take the vaccine have a preventative treatment called Varicella Zoster Immune Globulin (VZIG).
For more information, contact the National Immunization Hotline – (800) 232-2522.
It is my belief that I have had Varicella (chickenpox).
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No
If yes, Date
MM slash DD slash YYYY
As a child I lived with a sibling who had chickenpox
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No
If yes, Date
MM slash DD slash YYYY
I have cared for a child in my home who had chickenpox
Yes
No
If yes, Date
MM slash DD slash YYYY
Acyclovir is a medication I have taken for herpes viruses
Yes
No
If yes, Date
MM slash DD slash YYYY
My medical history includes having herpes zoster (shingles)
Yes
No
If yes, Date
MM slash DD slash YYYY
A blood test to establish my titer has been determined
Yes
No
If yes, Date
MM slash DD slash YYYY
A copy of the results is available and I have/can provide?
Yes
No
If yes, Date
MM slash DD slash YYYY
If no, or you cannot provide results, you may be asked to establish a titer by blood test.
If yes, the results can be provided within ten (10) business days and are available from:
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