Health History Questionnaire definition

Health History Questionnaire means a questionnaire completed by the Gestational Carrier and/or the Child’s biological father.
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Health History Questionnaire means a questionnaire about past or current health conditions.
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Health History Questionnaire. Immunization Records verification (including but not limited to MMR (Measles, Mumps, and Rubella), Varicella, Tetanus/T-dap, and the Hepatitis B series.  Influenza Vaccination: All students will be offered the influenza vaccine during flu season (early October – late March) and documentation will be kept to track the acceptance or declination of the vaccine. This can be done during the Colleague Tune-Up in October.
Sample 1

Examples of Health History Questionnaire in a sentence

  • Every effort will be taken to minimize these risks through the Health History Questionnaire and your individual consultation with your trainer.

  • If any information provided in the Enrollment Agreement or any of the Health History Questionnaire is incomplete or incorrect, it is the Client’s responsibility to notify ViaCord and correct that information immediately.

  • The Health History Questionnaire provides much of the required information, and complete, accurate information is critical to Release and use of Cord Blood Stem Cells.

  • In addition to the information in the Health History Questionnaire, use of Cord Blood Stem Cells requires some information about the Mother at the time of birth of the Child.

  • You will not be enrolled until You have completed the Informed Consent for Collection and Storage (attached as Schedule 1), and have completed or are facilitating the Mother’s completion of the Health History Questionnaire (attached as Schedule 2) and informed consent to testing of the Maternal Sample (attached as Schedule 3), and ViaCord has received a Medical Referral Form (provided separately) completed by Sibling’s treating physician with the qualifying condition.

  • For Xxxx Xxxxxxx collected in New York State, where possible, the Child’s biological father should also complete a Health History Questionnaire.

  • Health History Questionnaire (Non-Client Birth Mother) Annexure: 4.

  • In order to help Doctor get acquainted with your Medical History, please: • Complete the enclosed Health History Questionnaire, Patient Information Sheet and Notice of Privacy Practice Acknowledgement Form and bring it with you at the time of your visit.

  • The Client will also be required to submit the Maternity Health History Questionnaire and Infant Health History Questionnaire duly signed by a registered medical practitioner.

  • Signature of Participant: Print Name: Address: Phone: Date: Office Use Only background check payment received background check completed 3rd ride approved / dissapproved TB Health History Questionnaire Name: Please answer the following questions and return to Xxxxxx Xxxxx.


More Definitions of Health History Questionnaire

Health History Questionnaire means a form that is required to be completed by each person in the household, prior to enrollment that is submitted with the initial premium payment, that indicates any previously treated condition, or disease, or medication received by the person.
Sample 1

Related to Health History Questionnaire

  • Investor Questionnaire has the meaning set forth in Section 5.8.

  • Questionnaire shall have the meaning set forth in Section 2(a)(ii) hereof.

  • Collateral Questionnaire means a certificate in form satisfactory to Collateral Agent that provides information with respect to the personal or mixed property of each Credit Party.

  • Accredited Investor Questionnaire means the Accredited Investor Questionnaire set forth as Exhibit C-1 hereto.

  • Notice and Questionnaire means a Notice of Registration Statement and Selling Securityholder Questionnaire substantially in the form of Exhibit A hereto.

  • Selling Shareholder Questionnaire shall have the meaning set forth in Section 3(a).

  • Selling Stockholder Questionnaire shall have the meaning set forth in Section 3(a).

  • Administrative Questionnaire means an Administrative Questionnaire in a form supplied by the Administrative Agent.

  • Exhibit F The awarded category pricing from the Contractor’s submitted Price Sheet from 3rd Bid RFP 15-80101507-SA-D

  • list of accredited prospective providers means the list of accredited prospective providers which the municipality must keep in terms of paragraph 14 of this policy;

  • Exhibit 2 Standard File Codes – Delinquency Reporting, Continued The FNMA Delinquent Reason Code field should show the Reason for Delinquency as follows: Delinquency Code Delinquency Description 001 FNMA-Death of principal mortgagor 002 FNMA-Illness of principal mortgagor 003 FNMA-Illness of mortgagor’s family member 004 FNMA-Death of mortgagor’s family member 005 FNMA-Marital difficulties 006 FNMA-Curtailment of income 007 FNMA-Excessive Obligation 008 FNMA-Abandonment of property 009 FNMA-Distant employee transfer 011 FNMA-Property problem 012 FNMA-Inability to sell property 013 FNMA-Inability to rent property 014 FNMA-Military Service 015 FNMA-Other 016 FNMA-Unemployment 017 FNMA-Business failure 019 FNMA-Casualty loss 022 FNMA-Energy environment costs 023 FNMA-Servicing problems 026 FNMA-Payment adjustment 027 FNMA-Payment dispute 029 FNMA-Transfer of ownership pending 030 FNMA-Fraud 031 FNMA-Unable to contact borrower INC FNMA-Incarceration

  • Appendix Information means the information which must be provided for the selected modules as set out in the Appendix of the Approved EU SCCs (other than the Parties), and which for this Addendum is set out in:

  • Exhibit C Form xx Xxxxx B-4, B-5 or B-6 Certificate.................... Exhibit D: (Resexxxx)................................................... Exhibit E: Form of Reverse of Certificates.............................. Exhibit F: Form of Initial Certification of Master Servicer............. Exhibit G: Form of Final Certification of Master Servicer...............

  • Health care information means any information, whether oral or recorded in any form or medium that identi- fies or can readily be associated with the identity of, and relates to the health care of, a patient or client.

  • Exhibit D means Exhibit D to the Judgment;

  • Exhibit E means Exhibit E to the Judgment;

  • Exhibit B means [Vendor]’s Response.

  • Urgent care request means a claim relating to an admission, availability of care, continued stay or health care service for which the covered person received emergency services but has not been discharged from a facility, or any Pre-Service Claim or concurrent care claim for medical care or treatment for which application of the time periods for making a regular external review determination:

  • Exhibit means any item labeled as an Exhibit in the Solicitation or placed in the Exhibits section of the solicitation.

  • Information Package means the most recent compilation of financial and other data with respect to the Failed Bank, including any amendments or supplements thereto, provided to the Assuming Institution by the Corporation on the web site used by the Corporation to market the Failed Bank to potential acquirers.

  • Verbal abuse means, but is not limited to, the use of derogatory terms or names, undue voice volume and rude comments, orders or responses to residents.

  • Disclosure Counsel means the Special Counsel designated by the Corporation to be responsible for the drafting and delivery of the Corporation’s disclosure documents such as preliminary official statements, official statements, re-offering memorandums or private placement memorandums and continuing disclosure agreements.

  • Functional Acknowledgement means an acknowledgement Message by the receiving party’s computer software application which automatically confirms the receipt of a Message at the moment of receipt;

  • MI Report means a report containing Management Information submitted to the Authority in accordance with Framework Schedule 8 (Management Information);