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Get and Sign Standard Form 600 Medical Record 1997-2022
History:
Yes / No Have you received antibiotics in past month. If yes, NAME ________________
Yes / No Foreign travel in past month. If yes, COUNTRY _________________________
Yes / No If female, could you be pregnant? First day of last menses _________________
Yes / No Able to drink and keep down any fluids
Yes / No Eaten raw seafood recently or drank any untreated water? (streams, lakes, etc….)
Yes / No Decreased urination frequency LESS than every 8 hours?
Yes / No Other people sick who ate...
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