Vitalis Illness / Health Report - General

Vitalis Illness / Health Report - General

This information is purely for tracking purposes and to enable us warn other clients or staff about any public health issue.
Date*

MonthDayYear
Date
Name of Person Completing Form*

First NameLast Name
Role of Person Completing Form*
Is this Report for a Vitalis Client or Vitalis Staff?*

Vitalis ClientVitalis Staff
Name of Client*

First NameLast Name
Name of Staff*

First NameLast Name

Did you notify Agency supervisor?*

YesNo
Name of Supervisor informed?
Date

MonthDayYear
Date
Did you notify your physician?*

YesNo
Date

MonthDayYear
Date

What treatment was given?
Please provide additional details about the illness or health condition
Should be Empty: