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Get CA VA Northern California Health Care System Health History Form 2010-2024

First name: Last 4 SS#: Date of birth: ALLERGIC REACTIONS Allergen Initial Reaction Date Reactions CHILDHOOD DISEASES / INFECTIOUS DISEASES Have you had: Mumps Measles Rubella (German measles) Varicella (Chicken pox) Tuberculosis Hepatitis A Hepatitis B Hepatitis C Yes No Unk Comments No Unk Comments VACCINES / IMMUNIZATIONS / SKIN TESTS Have you had: MMR (Mumps, Measles, Rubella) Varicella (Chick.

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