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Medical Allergies
Are you allergic to latex?
Yes
No
Are you allergic to iodine?
Yes
No
Are you allergic to any medications?
Yes
No
Please list...
1.
Medication
Reaction
2.
Medication
Reaction
3.
Medication
Reaction
4.
Medication
Reaction
5.
Medication
Reaction
Food Allergies
Are you allergic to any specific foods?
Yes
No
Are you allergic to eggs?
Yes
No
Are you allergic to shellfish?
Yes
No
What foods are you allergic to?
What foods are you sensitive to?
(but not life threatening)
What environmental allergies do you have?
Immunizations
Have you ever had the following illnesses as a child?
(check all that apply)
None
Scarlet Fever
Diptheria
Rheumatic Fever
Mumps
Measles
German Measles
Mononucleosis
Chickenpox
Polio
Have you had any of the following immunizations:
(check all that apply)
None
Polio
MMR
Pertussis / Whooping Cough
Hepatitus A
Hepatitus B
Pneumonia
Small Pox
Anthrax
Shingles
Tetanus
Other
Please specify
Hernia Surgery
Have you ever had Hernia Surgery?
Yes
No
When did you have the hernia surgery?
Other Surgeries
Have you ever had any other surgeries?
Yes
No
Can you explain more...
1.
Surgery Date
Description
2.
Surgery Date
Description
3.
Surgery Date
Description
4.
Surgery Date
Description
5.
Surgery Date
Description
Hospitalized
Have you ever been hospitalized for any reason?
Yes
No
Can you explain more...
1.
Date Admitted
Reason
2.
Date Admitted
Reason
3.
Date Admitted
Reason
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