Medical & Vaccination History Form

First Name

Middle Name

Last Name

Date of birth

Home Address

Phone/Mobile

Weight (in Kilograms)

Medical History

Please provide your health information as accurately as possible.

Are you currently pregnant or breastfeeding?

Yes

No

Not applicable

Have you received any vaccinations within the past 28 days?

Yes

No

Please indicate which vaccine(s):

8. Have you had a fever within the last 7 days?

Yes

No

Do you have a personal history of HIV/AIDS, Hepatitis B, Hepatitis C, or other blood-borne illness?

Yes

No

Have you recently undergone radiation or chemotherapy or used immunosuppressive drug therapies including Humira, Remicade, Enbrel or high dose corticosteroids?

Yes

No

Do you currently have any medical conditions leading to suppressed immune function, ie. HIV infection, leukemia, lymphoma, thymic disease, generalized malignancy?

Yes

No

Are you aware of any existing or past issues with your liver or kidneys?

Yes

No

Do you have a personal history of blood clots?

Yes

No

Do you have a personal history of blood clots?

Yes

No

Do you have any known allergies?

Yes

No

What are you allergic to?

Please write all prescription and non-prescription medications that you are on. Include name, dosage and frequency.

Vaccination History

Please bring your vaccination record (if you have) with you to appointment

Annual influenza (flu shot)

Yes

No

Unsure

Tetanus

Yes

No

Unsure

MMR

Yes

No

Unsure

Varicella (Chickenpox)

Yes

No

Unsure

Hepatitis A

Yes

No

Unsure

Hepatitis B

Yes

No

Unsure

Yellow Fever

Yes

No

Unsure

Tick borne encephalitis

Yes

No

Unsure

Travelers diarrhea (Dukoral)

Yes

No

Unsure

Pneumococcal

Yes

No

Unsure

HPV

Yes

No

Unsure

Polio

Yes

No

Unsure

Shingles

Yes

No

Unsure

Japanese encephalitis

Yes

No

Unsure

Typhoid

Yes

No

Unsure

Meningitis

Yes

No

Unsure

Upload any relevant documents if you have any (optional)

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