|
|
Yes |
No |
Don't know |
| 29. |
Do you have any
allergy problems? |
|
|
|
| 29.1 |
Do you have any
hay fever symptoms? |
|
|
|
| 29.2 |
Do you have food
allergies? |
|
|
|
| 30. |
Are you allergic to
any medication? |
|
|
|
|
30.1 If
yes, list the medication to which you are allergic:
|
| 31. |
Have you had a
tetanus shot in the last 10 years? |
|
|
|
| 31.1 |
Do you have an
annual flu vaccine? |
|
|
|
| 31.2 |
Have you had a polio
immunization series? |
|
|
|
| 31.3 |
Have you received
the Hepatitis A vaccine? |
|
|
|
| 31.4 |
Have you received
the Hepatitis B vaccine series? |
|
|
|
| 31.5 |
Have you received
any recent immunizations (for travel, work, etc.) |
|
|
|
| |