ࡱ> PcO &bjbj++ YII.rrrrr8<4.."PPP#%%%%%%$N"Ir1^^^11IrrPP^;;;1|rPrP#;1#;;;P0RƷ;t0;"/";"r;>,;&$JII51111" 8:  Travel Health History Please be sure to answer all questions below as completely and accurately as possible and include copies of all available immunization records. This information will be used in planning for your travel health recommendations, which will be prepared as soon as the information is received. An incomplete questionnaire may delay your recommendations and immunizations. All information is strictly confidential. Please print clearly. Please Note: Completion of this form is not guarantee of an appointment Name__________________________________Age________Sex M F Address_____________________________________________________ City____________________ State (country) _______________Zip________ Home Phone__________Business phone__________Cell Phone_________ Email_________________________________ Date of Birth__________________Place of Birth______________________ Weight (approximate) ______lbs Social Security #____________________ Have you ever been a patient at our Travel Immunization Center before? No Yes If yes, when? ___________ Business travelers: Please indicate company or organization: ____________ _____________________________________________________________ 1. Planned Itinerary---in EXACT ORDER of Travel: Departure Date: _______________Return Date (approximate) ____________ Any Country (list cities) Length of Stay Rural Travel (Circle) 1.________________________ ________________ No Yes 2.________________________ ________________ No Yes 3.________________________ ________________ No Yes 4.________________________ ________________ No Yes 5.________________________ ________________ No Yes 6.________________________ ________________ No Yes 7.________________________ ________________ No Yes 8.________________________ ________________ No Yes Attach printed/detailed itineraries (e.g. from cruise line, travel agent, etc.) If available 2. Accommodations: (Check all that apply) ___Resort ___Cruise Ship ___Private Home ___Camp ___Dormitory ___Major Hotel ___Small Hotel ___Youth Hostel ___Other____________ 3. Purpose of Travel: (Check all that apply) ___Business ___Teaching ___Biking/Hiking ___Volunteer -Organization ___Vacation ___Diving ___Safari ___Foreign -Study ___Climbing ___Missionary ___Other________________________________ 4. Medical History: Do you have any allergies? (Drugs, foods,--especially eggs) No Yes If yes, please describe allergy and reaction___________________________ _____________________________________________________________ Have you ever had any of the following? (Circle yes or no. If yes, give details and dates) Fever in the past 48 hours No Yes ____________________ Diabetes No Yes ____________________ Heart Disease No Yes ____________________ Kidney Disease No Yes ____________________ Stomach Diseases (ulcer, etc.) No Yes ____________________ Respiratory Disease (asthma, etc.) No Yes ____________________ Neurological Disorder No Yes ____________________ Seizure Disorder? Epilepsy No Yes ____________________ Depression No Yes ____________________ Psychiatric Disorder No Yes ____________________ HIV or Immune Deficiency No Yes ____________________ Cancer or Leukemia No Yes ____________________ Hives No Yes ____________________ Psoriasis (diagnosed by a physician) No Yes ____________________ Myasthenia gravis, DiGeorge Syndrome or thymoma/thymus Surgery No Yes ____________________ 5. Current Medications: Are you taking any medications? No Yes List all current medications and dosage schedules (including oral contraceptives and over the counter drugs):__________________________________________ _____________________________________________________________ 6. Immune System**Have you ever received any of the following treatments? Treatment Reason Dates Radiation Therapy No Yes __________________________ __________ Cancer Chemotherapy No Yes __________________________ __________ Have you taken Cortisone/Steroids or other medications that affect the immune system? No Yes Indicate the reason and the dosages, forms (pills, injection, inhaler, etc.), dates and duration of treatment. ___________________________________________________________________________ ___________________________________________________________________________ Do you live with (or work closely with) anyone who had AIDS, an AIDS-like condition, a suppressed immune system, or who is receiving any of the treatments/medications listed above? No Yes **The purpose of these questions is to assist us in assessing any possible risk to you or your contacts from certain immunizations. 7. Prior Immunizations: Indicate the month/year of all doses received. Please respond for each and attach copies of all available immunization records. Tetanus Gamma Globulin Diphtheria Hepatitis A Vaccine Measles Hepatitis B Vaccine Mumps TyphoidInjected Rubella TyphoidOral Polio (series & booster) Yellow Fever Influenza (flu shot) Cholera Pneumococcal (Pneumonia) Rabies Meningococcal (Meningitis) Japanese Encephalitis Varicella (Chicken Pox) Other Have you ever had an adverse reaction to any immunizations? No Yes If yes, specify immunization and reaction: __________________________ ____________________________________________________________ ____________________________________________________________ 8. WOMEN ONLY: Are you pregnant now or do you suspect that you might be pregnant? ______ Are you planning a pregnancy in the next six months? ________ When was your last menstrual period? Date: ______________ 9. PHYSICIAN INFORMATION: Who is your personal physician? Name___________________________________________________ Address____________________________City__________________ State________________ZIP_______________Phone______________ 10. ADDITIONAL INFORMATION: Please include any additional information that you think might assist us in preparing your travel health recommendations: _______________________ _____________________________________________________________ _____________________________________________________________ Please check to make sure that you have answered ALL questions. Incomplete forms may delay processing. Please sign below and return the completed form to initiate the preparation of your travel health recommendations and immunizations (unsigned forms cannot be processed). ________________________________________ ________________ Signature Date The information provided in this questionnaire is not a substitute for medical advice from a health care provider on an individual basis. Travel-related vaccines and medications are generally not covered by health insurance. The patient is responsible for payment in full at the time of service. Our physicians will be happy to see you for any travel related illness, but this visit is not included in the travel clinic consultation fee. This will result in a separate charge, billed to your insurance if applicable. 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