Medical History Form 1Medical History Form 1
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NOVA SOUTHEASTERN UNIVERSITY HEALTH CARE CENTER
PATIENT HISTORY FORM
Patient’s Name: _______________________________________

Today’s Date: _______________________________

Social Security Number: ________________________________

Date of Birth: ________________________________

Past Medical History
Previous Physician’s name: ______________________________
Have you ever been hospitalized?
Have you ever been tested for hepatitis A, B or C?
Have you been vaccinated for hepatitis B?
Have you been vaccinated for hepatitis A?

□Yes
□Yes
□Yes
□Yes

□No
□No
□No
□No

Date of last exam: ____________________________
If yes, what for? _____________________________
Which hepatitis virus?___________________
If yes, date vaccine series completed _____________
If yes, date vaccine series completed _____________

Last Tuberculosis (TB) Screening? _________________________

Result of TB screening:

If positive TB screen, date of last chest x-ray: _________________

Result of chest x-ray:

Have you had