Patient Forms

Travel Form

 

Demographic Info

 
First Name Last Name
Phone Number Date of Birth
.

Travel Companions

Travelling with your spouse? Yes    No 
Travelling with your children? Yes    No 
**If travelling alone, skip to next section.
 
Spouse Name
 
Children(s) Names
 
 

Travel Info

 
Have you consulted our office for travel in the past? Yes    No 
 
Destination
Departure Date
Return Date
Length of Trip
Reason for Travel
Type of Travel
Is this a Work Expense? Yes    No 
Accommodations
Please list name of group or organization overseeing travel, if applicable.
Do you need an exam or paperwork filled out prior to trip? Yes    No 
 
 
 

Travel History

 
Have you been outside of the US before? Yes    No 
Please list previous countries visited and year of visit.
 

Immunization History

For each immunization, please list date of last immunization.
You may have shot records sent to us, if preferred. Our fax number is 937-433-8691.
 
Yearly Flu Vaccine
Gamma Globulin
Hepatitis A
Hepatitis B
Japanese B Encephalitis
Lyme Disease
Meningococcal
MMR (Measles, Mumps, Rubella)
Oral Polio (OPV)
Injected Polio (IPV)
Oral Typhoid Vaccine
Injected Typhoid Vaccine (Typhim Vi)
BCG (TB)
Rabies
TD (Tetanus, Diphtheria) or Tdap (Tetanus, Diphtheria, Pertussis)
Yellow Fever
Other Immunizations
 
Any adverse reaction to any of the above? Yes    No 
If yes, which one(s). Explain reaction.
 
If you were born prior to 1957, have you been immunized against measles since 1980? Yes    No 
 
If you were born after 1957, have you had measles? Yes    No 
 
 

Family History

 
Father
Any Major Health conditions or concerns?
Date and Cause of Death
 
 
Mother
Any Major Health conditions or concerns?
Date and Cause of Death
 
 
Sibling 1
Any Major Health conditions or concerns?
Date and Cause of Death
 
Sibling 2
Any Major Health conditions or concerns?
Date and Cause of Death
 
Sibling 3
Any Major Health conditions or concerns?
Date and Cause of Death
 
 
Please list any Blood Relatives with Major Health conditions or concerns. Include relationship and problem.
 
 
Please list all allergies, including Food, Drug, and Environmental Factors.
 

Brief Medical History

Please mark Yes if you have had any history of the problem.
 
Depression/Anxiety Yes    No 
Other Psychiatric Issue Yes    No 
Heart Yes    No 
Hepatitis Yes    No 
Psoriasis Yes    No 
Seizures Yes    No 
 
Smoking History
Have you ever smoked regularly? Yes    No 
How many years?
How many packs a day?
When did you stop?
 
Alcohol History
Have you ever consumed alcohol regularly? Yes    No 
How many years?
How many drinks a week?
When did you stop?
 
Street Drug History
Have you ever used drugs regularly? Yes    No 
What drugs?
How long?
When did you stop?
 
 

Medications

Please mark Yes if you currently take any of the following medications.
 
Quinidine Yes    No 
Anti-Seizure Yes    No 
Beta Blocker Yes    No 
Calcium Channel Blocker Yes    No 
Other Heart Medication Yes    No 
 
Please list all current medications and vitamins.
 
Are you pregnant or planning to become pregnant in the near future? Yes    No 
 
Do you have an immune deficiency? Yes    No 
 
 
Did you fill out the Pre Registration Form? If not, please complete that form next.
 
 
 
SOME SERVICES MAY NOT BE COVERED BY YOUR INSURANCE PLAN.
After billing your insurance, we will bill you for any non-covered service.
PAYMENT IN FULL IS DUE UPON RECEIPT.
 
Entering my name indicates my agreement to pay any fees not covered by insurance.
 
 

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