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1.I WAS IN
THE HOSPITAL FOR (list Conditions) Date
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2.I HAVE HAD THESE SURGERIES: Date
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3. I HAVE HAD THESE INJURIES/CONDITIONS/
ILLNESSES: Date
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4. I HAVE
THESE ALLERGIES (list type of allergy -
e.g., food, medicine --- and reaction):
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5. I HAVE
HAD THESE IMMUNIZATIONS (SHOTS):
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For
children: Date(s) received
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Hepatitis B
(HBV)
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Polio
(IPV/OPV)
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Diphtheria,
pertussis and tetanus (DPT)
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Measles,
mumps and rubella (MMR)
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chickenpox
(varicella) (VZV)
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Tetanus
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6. I TAKE
THESE MEDICINES/SUPPLEMENTS:
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General
Name Brand Name Dosage
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7. MY FAMILY MEMBERS (PARENTS, BROTHERS, SISTERS,
GRANDPARENTS) HAVE/HAD THESE MAJOR CONDITIONS:
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Relatives
Condition
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8. I SEE THESE DOCTORS:
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Name Why I
see them
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