Wisconsin Initial Refugee Health Assessment Page 2
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6F-42017 (Rev. 09/13)
Page 2 of 6
Past Medical History
Current Medications
None
Yes (list/attach)
Medication Allergies
Herbal/Traditional treatments
None
Yes (list/attach)
______________________
None
Yes (list/attach)
Vision problems:
Yes
No
Musculoskeletal:
Yes
No
Hearing problems:
Yes
No
Skin:
Yes
No
Dental problems:
Yes
No
Endocrine:
Yes
No
Cardiovascular:
Yes
No
Neurological/seizures:
Yes
No
Respiratory:
Yes
No
Mental Health concern:
Yes
No
Gastrointestinal:
Yes
No
Tobacco (type, amt):
Yes
No
Genitourinary/Renal:
Yes
No
Alcohol use:
Yes
No
Pregnant:
Yes
EDD:
No
Drug use:
Yes
No
LMP:
G:
P:
AB:
Other (ie, betel nut use, khat)
Family/Social History
Diabetes:
Yes
No
Hypertension:
Yes
No
Sickle Cell Anemia:
Yes
No
Other:
Yes
No
Travel History (country of birth, route to U.S.):
Occupational History (i.e., environmental, chemical exposures):
________________________________________
__________________________________________________
Vaccine – Preventable Disease/Immunization
Overseas immunizations done
Check if there is evidence of immunity; no
Mo/Day/Yr
Mo/Day/Yr
Mo/Day/Yr
Mo/Day/Yr
Mo/Day/Yr
Mo/Day/Yr
immunization needed
Measles
Mumps
Rubella
Varicella (VZV)
Diphtheria, Tetanus, and
Pertussis (DTaP, DTP,
DT)
Diphtheria Tetanus
(Td)/Tdap*
Polio (IPV)
Hepatitis B (Hep B)
Haemophilus influenza
type b
(Hib)
Hepatitis A (Hep A)
Influenza
Pneumococcal (PCV3**,
PPSV23)
Meningococcal conjugate
(MCV4)
Rotavirus
Human Papilloma Virus
(HPV)
Zoster (shingles)
*Tetanus, diphtheria and acellular pertussis (Tdap) vaccine is recommended to satisfy the Td booster requirement. Tdap vaccine can be
administered to persons 7 years of age and older.
**Children less than 6 years of age should receive the PCV13 vaccine. Adults aged 65 and older should receive one dose of PPSV23.
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