Travel clinic form.indd
METHODIST TRAVEL CLINIC
10060 Regency Circle
(402) 354-1530You 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: ___________________________________
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?
1. Were you born in the United States? Yes No If no, where: ______________________________________________
2. Have you completed the following immunizations?
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)?
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.
BELOW THIS LINE IS FOR OFFICE USE ONLY:Date and time of appointment: ______/ ______/______ at ______ am pm
des rencontres scientifiques du vieillissement des 6, 7 et 8 novembre 2013 à Toulouse ( Dr Christine DEMAISON-BONFORT) Généralités • Pour la BPCO du sujet âgé, utiliser des sprays ( bronchodilatateurs et de corticoïdes) avec chambre d'inhalation. • Lors de l'instauration d'un traitement anti-hypertenseur, le risque de chute est très
THIS IS AN ADVERTISEMENT HOSPITAL ENVIRONMENTAL LAW COMPLIANCE Louisville Bar Briefs May 2009 By Ronald R. Van Stockum, Jr., Esq., Attorney at Law1 and LaJuana S. Wilcher, Esq., Attorney at Law2 “Repugnant, intolerable, unacceptable.” That was the response of Congress in 1988 to the wash-up on New England beaches of medical debris such as needles, syring