INITIAL REFUGEE HEALTH ASSESSMENT FORM

INITIAL REFUGEE HEALTH ASSESSMENT FORM
CT Department of Public Health - Refugee and Immigrant Health Program
410 Capitol Avenue, Hartford, CT 06134-0308
Voice:(860) 509-7722 – Fax:(860) 509-8271
Patient Information
Patient's Full Name

First NameMiddle NameLast Name
Alien Number:
Date of Health Assessment:

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / ZIP Code
Sex
U.S. Entry Date

MonthDayYear
Country of Birth
Patient’s Date of Birth

MonthDayYear
RACE AND ETHNICITY (PLEASE CHECK ALL THAT APPLY):
Interpretation Used:
Interpretation Language
Overseas TB Class Status?
Immunizations (U.S. Only)

Lab Evidence of Immunity

Rows	Negative	Positive	Indeterminate
Hepatitis A Total Antibodies
Measles
Mumps
Rubella
Varicella

If vaccine given in the U.S.

Rows	Date
DIPHTHERIA, TETANUS, AND PERTUSSIS (DTaP/Tdap):
DIPHTHERIA – TETANUS (DT/Td):
HAEMOPHILUS INFLUENZA TYPE B:
HEPATITIS B:
HUMAN PAPILLOMA VIRUS:
INFLUENZA:
MENINGOCOCCAL CONJUGATE:
PNEUMOCOCCAL:
POLIO:
ZOSTER (SHINGLES):

Please list any additional vaccines given in the U.S. (Click the save button to add additional items)
Tuberculosis Screening - Report Tests Done in U.S. Only
Date of Tuberculin Skin Test (TST)

MonthDayYear
Induration (MM)
Tuberculin Skin Test (TST) - Result
Date of IGRA Test

MonthDayYear
IGRA Type:
IGRA - Result
Date of Chest X-Ray (U.S. Only)

MonthDayYear
Referred?
Chest X-Ray U.S. - Result
Tuberculosis Diagnosis – Diagnosed in U.S. Only
Type of Infection or Disease (Must Check One)
LTBI Treatment Started?
Hepatitis B & C Screening

Screening Results

Rows	Negative	Positive	Indeterminate	Not Done
ANTI-HBs [If Positive, Patient is IMMUNE]
HBsAg [If Positive, Patient is INFECTIOUS]
ANTI-HBc
ANTI-HCV

Screening Results

Screenings

Rows	Yes	No
Serology Test
Schistosoma
Strongyloides
Stool Specimen (Ova & Parasites)

Screenings