Emory Healthcare Initial History Form Page 2

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In your own words, why are you here to see an Infectious Diseases physician?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What medications are you taking (including vitamins, herbs, over-the-counter pills)?
Name of Drug
Dose
Taken how often?
For what purpose (diagnosis)
Have you ever had allergies to medications?
No
Yes
Drug
Reaction
Drug
Reaction
Please list all of your Medical problems (hypertension, diabetes, etc)
Medical Problem
When diagnosed?
Please list all of your Surgeries and Hospitalizations
Surgery, Hospitalization
Dates (approx)
Where treated?
Have you had these vaccinations?
Vaccine
Last date
Vaccine
Last date
Pneumovax
Hepatitis A
Influenza
Hepatitis B
Tetanus (TDAP)
Chickenpox or Shingles
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