Travel clinic form.indd

10060 Regency Circle
(402) 354-1530
You may fax completed form back to (402) 354-1535
Today’s Date: ______/ ______/ ______ (MM/DD/Year) Last Name: _______________________________________ First Name:___________________________________________ Address: ______________________________________________________________________________________________ City: ____________________________________________ State: ___________________________ Zip: _________________ Date of Birth: ______/ ______/ ______ Gender: Home Phone #: ___________________________________ Work Phone #: _________________________________________ Cell Phone #: _______________________________ E-mail address: ______________________________________________ Emergency Contact: _______________________________ Contact’s Phone Number: ________________________________ Primary Care Physician: ____________________________ Physician’s Phone Number: _______________________________ Travel Specifi cs:
School/Company’s Name: ___________________________________ Other: ______________________________________ 2. What will you be doing on this trip? _______________________________________________________________________3. Does your program require completion of a medical form by a practitioner? 4. Are you currently enrolled in a health insurance plan that covers you while you are overseas? Unsure No Yes If yes, what insurance plan do you have? ______________________________________ 5. Departure Date from the United States:______________ 6. Return Date to the United States:_________________________ Countries and Cities to be visited in order of visits 7. Have you traveled outside the US before? Yes No If yes, where and when? _________________________________________________________________________________8. Will you be visiting only urban areas? Yes No If no, explain: _______________________________________________ Staying only in hotels? Yes No If no, explain: ________________________________________________________ V Ascending to high altitudes (>7,000 feet or 2,300 meters) in the mountains? Working in a medical or dental fi eld with exposure to blood/other body fl uids? Potentially having sexual contact with new partners? Immunizations:
1. Were you born in the United States? Yes No If no, where: ______________________________________________
2. Have you completed the following immunizations?
Medical History:
1. Are you taking steroids, receiving radiation therapy, or other immunosuppressive chemotherapy?
If yes, what?___________________________________________________________________ 2. Please list your current prescription medications and the medical conditions being treated. (include birth control pills) 3. Please list regulary used non-prescription medications (over-the-counter, herbal, homeopathic, vitamins, etc.)Regularly Used Non-Presciption Medications 4. Have you been told you have any of the following medical conditions (check all that apply)? Other: ___________________________________________________________________________________________ Allergies:
1. Have you had a reaction to any of the following? (please check all that apply)
Pyrimethamine Antibiotics (e.g., Neomycin, Streptomycin) Thimerosal (preservative in contact lens solution) Quinines (Chloroquine [Aralen], Mefl oquine [Lariam] Hydroxychloroquine [Plaquenil], or Primaquine) Tetracyclines (Doxycycline, Minocin, Minocycline, Acromycin, Sumycin) 2. Do you have any food or drug allergies not listed above? If so, please list:______________________________________ For Women Only:
a. When was your last menstrual period? ______________________________
b. Are you, or could you possibly be, pregnant?
Questions or Concerns: Please list additional questions or concerns that you might have regarding your travel. (i.e.
dealing with motion sickness, altitude sickness, etc.) ________________________________________________________
How did you hear about us?
Word of Mouth, if so who: ________________________
Internet, if so what website________________________ Marketing Materials: _____________________________
Referral from your physician – Dr: ___________________ Other, please explain: ____________________________
By signing below, I acknowledge that the information contained in this document is accurate and complete to the bestof my knowledge. If medications will be prescribed to me, I understand that the clinic is operating under a drug therapymanagement protocol with the medical director, and I consent to be treated following this protocol.
X______________________________________________________ ___________________________________Signature BELOW THIS LINE IS FOR OFFICE USE ONLY:Date and time of appointment: ______/ ______/______ at ______ am pm



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