New Patient Form-Travel Clinic
Name: ______ / Clinic Visit Date: ______/______/______Date of Birth: _____/_____/______ / Age: ______
(Weight if child) ______lbs.
Cell Phone: _____-______-______ / Email:______
Mailing Address:
______
Street
______
City State Zip
Primary Care Provider: ______
*If patient is under 18***
Guardian name:______
Insured adult:______
Guardian date of birth: ______/______/______ / Referred by:______
Would you like your Immunization record that you receive today faxed to your Primary Care Provider _____Y _____N
TRAVEL INFORMATION
Dates of Travel: ______/______to ______/______Departure from PC if different:____/______
ITINERARY- PLEASE LIST COUNTRIES IN EXACT ORDER:
1.______2.______3.______4.______5.______
6.______7.______8.______
Type of travel
Check all that apply / □ HighAltitude/Trek
8,000 or higher / □ City / □ Visiting family/friends / □ > 4 weeks in Asia
(JE)
□ Adventure-
Trek/Zipline / □ Rural / □ Mission Work / □ Communal Living (Dorm, hostel)
□ Cruise Ship
□ Scuba Diving / □ Travel with children / □ Adoption / □ Business
ALLERGIES
YES NO YES NO
• Penicillin or sulfa (Diamox) / □ / □ / • Yeasts (HA/B-HPV) / □ / □
• Eggs/Chicken (Flu ,YF, MMR, Var) / □ / □ / • Gelatin (Zos-YF-JE-MMR-Var-Fluzone) / □ / □
• Bee Stings (JE) / □ / □ / • Azithromycin / □ / □
• Thimerosal (Tdap-JE) / □ / □ / •Other Allergies: 1) ______2)______3)______ / □ / □
ALLERGIES and MEDICATIONS continued
Yes No Yes No
Taking Corticosteriods (e.g. prednisone) (In last 3 Months only) / □ / □ / Taking Oral Contraceptives (No Doxy) / □ / □
Taking Chemotherapy / □ / □ / Taking Anti-convulsants (Mefloquine) / □ / □
Taking Antacids (No Doxy) / □ / □ / Taking Asthma Medication / □ / □
Taking Blood Thinners / □ / □ / Taking Other Medications / □ / □
TakingAntibiotics (Oral typhoid) / □ / □ / If yes please list Medications: ______
HEALTH ASSESMENT / YES / NO
1. Have you had a fever or wheezing in the past 24 hours? / □ / □
2. Have you ever fainted or felt light-headed from an injection / □ / □
3. Have you ever had a severe reaction to a vaccination (e.g. short of breath or hives) / □ / □
4. Do you have Asthma? (Flu Mist) / □ / □
5. Do you have diabetes? ( Hepatitis B) / □ / □
6. Do you have a blood clotting disorder? / □ / □
7. Have you ever had Hepatitis? Which kind: A,B,C,D,E (Circle all that apply) / □ / □
8. Have you ever had a convulsion, seizure, epilepsy, or any neurological condition? / □ / □
9.Are you Immunocompromised due to an illness or cancer? (Thymus Disease,thymectomy,organ/ bone transplant, HIV, spleen ectomy, renal dialysis) / □ / □
10. Do you have a history of Guillain Barre Syndrome? (Flu, Menactra) / □ / □
11. Women only: (mark box if yes) Zike Virus and Live Vaccine Precautions
1. Are you Pregnant □ 2. Suspect you may be pregnant □ 3.May become pregnant next 3 months? / □ / □
12. Are you Breastfeeding?
HAVE YOU RECEIVED ANY LIVE VACCINES IN THE LAST 4 WEEKS (PLEASE CIRCLE IF YES)
MMR MMRV ZOSTAVAX (SHINGLES) VARICELLA (CHICKEN POX)
IMMUNIZATION HISTORY
ROUTINE IMMUNIZATIONS: □ SEE ATTACHED RECORD
Immunization / Date / Immunization / Date / Immunization / Date
Tetanus/Diphtheria (TD) / Polio Adult Booster / MMRV (live)
MMR adult booster
TDAP (Pertussis-Adacel) / Tetanus/TD only / Meningococcal
Zostavax (Shingles live) / Varicella (Chicken Pox live) / HPV 1, 2, or 3 doses
Pneumonia / Seasonal Flu / TB Skin Test
TRAVEL IMMUNIZATIONS: □ SEE ATTACHED RECORD
Immunization / Date / Immunization / Date / Immunization / Date
Hepatitis A #1
Hepatitis A #2 / Hepatitis B #1
Hepatitis B #2
Hepatitis B #3 / Twinrix HepA/B #1
Twinrix Hep A/B #2
Twinrix Hep A/B #3
Typhoid Shot
(2 years) / Yellow Fever (10years) / Japanese Encephalitis #1
Japanese Encephalitis #2
Oral Typhoid
(5 years)
Pre exposure/ Rabies
Dose 1, 2 or 3 / Other
IPV=Polio, HPV=Gardasil, HA/B=Hepatitis, PPV=Pneu23, JE=JapEnceph, Typh=Typhoid inject, TD=Tet-dipth, Tdap=tet,depth,pertus Zos=Zosta
ADVANCE BENEFICIARY NOTICE
NOTE: You need to make an informed choice about having your travel consultation and immunizations. Insurance companies will not cover travel vaccines therefore; we require all fees to be paid at the time of service. Routine immunizations can be billed to your insurance company however, some may not be covered under your plan and you will be responsible to pay the remainder of the balance once insurance has been processed.
Thank you for your cooperation.
I understand and agree with the above conditions.
______
SignatureDate
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