MASSACHUSETTS REFUGEE HEALTH ASSESSMENT PROGRAM (RHAP)
REFUGEE HEALTH ASSESSMENT FORM
Address:
Family Name: First & Mid:
A#:
Nationality: Resettlement Agency:
Arrival Date:Birth Date:
Tel:
M FSex:
Clinician Name:Primary Care - Site:
Appt1:
CLINICIAN: INTERPRETER:
Immunizations: Attach immunization record or fill in the table on page 2. Record ALL valid doses for which you have documentation.
Basic Health Screening
NL ABNL Wgt (lb): Hgt (in): BP: Hgb: MCV:
Vision:
WBC: EOS (%): Plt Ct: Pb:
Hearing: UA Sugar: UA Protein: UA Blood:
uHCG1:
Neg Pos
uHCG 2:
Neg
Pos
Dental:
Tob. Use:
Yes No
Alc. Use:
Yes No
RHS-15 Q1-14:
/56
Distress
/10
Therm:
10/2013
Division of Global Populations and Infectious Disease Prevention, MDPH
305 South Street, Jamaica Plain, MA 02130 Tel: 617-983-6590 FAX: 617-983-6597
RETURN COMPLETED FORM TO:
MR#:RHAP SITE: Appt2:
None:
PCP Appt dt:
Referrals
Domestic Presumptive Treatments: Record treatment in the "medications prescribed" section.
Antimalarial Antihelminthic
MAVEN ID:
Comments:
Cardiology
Dental Dermatology Disability Svcs
Endocrinology ENT GI
Hem/Onc Mental Hlth
Neurology OB/GYN Orthopedics TB Clinic Vision WIC Other:
Overseas Medical Examination
NoYes
NoYes
No overseas documentsDS-2054 Reviewed:
IOM Bag Reviewed:
Tuberculosis
TST (mm): Plant Date: Read Date:
ABNLNLOverseas chest X-ray:
BCG:
Date:
T-SpotQuantiFERON Result: PositiveNegative Indeterminate/BorderlineIGRA Type:
Hepatitis B
HBsAg:
PosNeg
AntiHBs:
PosNeg
Intestinal Parasites: Record treatment in the "medications prescribed" section.
None Ascaris Giardia Strongyloides
Blastocystis H. nana Trichuris
E. histolytica Hookworm Other
Stool O&P Done?
Neg
Pos
Giardia FAb
:
Asylee?
HIV
HIV-1 antibody:
Neg Pos Offered, but refused
HIV-2 antibody:
Neg Pos Offered, but refused
Yes
No
Stool Not Returned
H&P Done
ID
Other Diagnoses Medications Prescribed Health Education
1. 1.
Vaccines Access to care
2. 2.
Primary Care Insurance
3. 3.
Oral Health Emergencies
4. 4.
5. 5.
MVI Dispensed Vit D TX
Class A/B conditions:
None A B TB B Other
Neg Pos
Varicella Titer:
Exam
History
Immune by:
Antimalarial Antihelminthic
Pre-departure Presumptive Treatment?:
Unknown
02/2017
Revised 02/2017
HBcAb
HBcAb:
Neg Pos
HCV Ab: Neg PosPosNeg
AntiHBcA
AntiHBcAb:
Neg Pos
Revised: October, 2017
