Health History

Name *
Name
Date of Birth *
Date of Birth
5. Date of Last Tetanus Vaccine:
5. Date of Last Tetanus Vaccine:
Date of Last Pneumonia Vaccine:
Date of Last Pneumonia Vaccine:
Date of Last Influenza Vaccine:
Date of Last Influenza Vaccine:
Date of Last Zostavax (Shingles) Vaccine:
Date of Last Zostavax (Shingles) Vaccine:
7. Do you drink alcoholic beverages: *
8. Do you smoke/chew tobacco? *
9. Do you use or abuse other substances or drugs? *
Family Medical History
Please list family members (parents, grandparents, uncles, aunts, brother, sisters, children) who have the following: