VARICELLA REPORT FORM - Lorain County General Health District 2026

1. Click ‘Get Form’ to open the VARICELLA REPORT FORM in the editor.
2. Begin by filling out the Demographic Information section. Enter the child's name, date of birth, age, and gender. Select the race and ethnicity options that apply.
3. Provide the child's address, city, state, and zip code. Then, enter the parent's name and phone number for contact purposes.
4. Move to the Clinical Information section. Indicate whether a rash is present by selecting 'Yes', 'No', or 'Unknown'. Fill in the onset date and location of the rash.
5. Answer whether there was a fever and if the child received the Varicella vaccine. If applicable, provide vaccination dates for both doses.
6. Assess and select the severity of Varicella based on lesion count. Indicate if hospitalization occurred and provide diagnosis details.
7. Complete the Reporting Information section with your name, agency/site name, and type before submitting.
8. Finally, fax or mail this completed form to Lorain County General Health District as instructed at the bottom of the form.

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