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Express registration form


This 2 page form asks basic medical history of the patient so that they can be issued medication as prophylaxis.  This would serve as an important template for other health departments that do not have a simple questionnaire such as this.  Prophylaxis can have adverse affects, and the questions included on this form aim to avoid such affects. 


Medical Countermeasure (MCM) Toolkit

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LaPorte County Health Department




The NACCHO Toolbox is a repository of available resources to help local public health practitioners. Tools are produced by local, state, and federal agencies, as well as academic institutions and other stakeholders. The contents of this Toolbox are solely the responsibility of the authors and do not necessarily reflect any official recommendations of NACCHO. NACCHO makes no express or implied warranty with respect to the contents and disclaims liability for any damages arising from or connected to the use of the material in this Toolbox.