PL_Pub_Notebook_Winter_2014_f - page 5

Notebook • Winter 2014
5
Used with permission from the Virginia Adult Learning Resource Center. http://www.valrc.org/
Virginia Adult ESOL Health Literacy Toolkit
© 2012 VALRC
6.4.1
6.4 My Medical History
Name: _______________________ Date of Birth: _____________
Health problems I have:
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
______________________________________________________
Allergies I have:
______________________________________________________
______________________________________________________
______________________________________________________
Medicines I take:
Name:
Dose:
Times I take it:
Surgeries:
Name of surgery:
Date:
Health problems in my family: ______________________________
______________________________________________________
______________________________________________________
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