4 page travel history sheets nov .06

International Travel Health and Vaccination Clinic Inc.
Countries to be visited, Departure Return Would you be willing to be contacted with information about vaccine clinical trials for which you may be eligible? PLEASE FILL OUT THE FOLLOWING MEDICAL HISTORY PAGE
PLEASE READ THE “SERVICE CHARGES” PAGE ON THE NEXT PAGE OF THIS CHART
Counselling charges include risk assessment - documentation - written information - and all follow-up appointments needed to complete pre travel preparations and vaccinations.
** Vaccines and other supplies are not included in the service charge.**
OFFICE VISIT PRICES ARE AS SEEN ON OUR WEBSITE Your Travel Consultant will advise you as to the office visit and vaccination prices.
I acknowledge that the above fees are not covered by the Medical Services Plan, and that I am
responsible for payment, and I also acknowledge that the cost of vaccines and supplies are
extra.
Fees, and charges for vaccines, and supplies may be covered by your Extended Benefits Plan,
and/or may be income tax deductible. Complete receipts will be supplied. You will also receive full
medical documentation necessary for your travel.
- Do you tend to faint following injections?- Have you ever had a fever after vaccination? - Have you ever reacted badly to a vaccine? - Do you have a problem with your immunity? - Have you received any blood products or - Do you have a medical condition for which you are taking medications or seeing an MD?- Have you had a fever in last 24 hours? Cholera, DTP, TD, Influenza,Menningcoccol, Oral typhoid,Pneumococcal - Are you pregnant or planning to be while away? MMR, Oral typhoid, Varicella,Yellow Fever, Doxycycline,Lariam, Antibiotics - Do you have a blood or clotting disease or a history of clots in the veins of your legs? Oral typhoid, Mefloquine,Doxycycline, Diarrhea - Have you ever had hepatitis or jaundice? - Do you have a history of psychiatric illness? - Do you have a problem with strange dreams and/or nightmares or insomnia? - Have you ever had Malaria?- Have you ever had Dengue Fever? Decreased immunity - needsmultiple vaccinations Please list any Prescription Medications you take:
- Quinine, quinidine, or other cardiac medication? - Are you on Antidepressants? Medications for emotional problems? Please list your drug and non drug allergies - Stroptomycin - Neomycin - Gentamycin - Polymyxin? Twinrix- Hep A - IPV - MMR -Rabies - varivax -flu - Bee stings or history of hives or itchy rash? IPV, Meningcoccal, Oral Typhoid,Rabies, Pneumococcal I, have completed the medical questionnaire to the best
of my knowledge and I am aware of all clinic service charges / vaccine charges.
*** STOP HERE ***
Only Yellow Fever Vaccine Candidates must complete the section below HAVE YOU ANY OF THE FOLLOWING,
Persons who are allergic to eggs, chicken, gelatin or previous Yellow Fever vaccination.
Infants younger than 9 months of age.
Persons who have a suppressed immune system.
Persons who are possibly pregnant, or may be while traveling Persons who have had cancer or any cancer treatment including drugs and /or radiation.
Persons who have recently been on cortisone medication for over two continuous weeks.
Persons who have had Thymus Gland surgery - Myasthenia Gravis - DiGeorge Syndrome All vaccines including Yellow Fever can have the following adverse reactions:
Fever - General Fatigue - Soreness / redness or swelling at the site of injection.
Serious Adverse reactions to Yellow Fever Vaccine (explained in detail at your visit to the clinic).
Non life-threatening allergic reaction (approximately 1 per 131,000 doses) Yellow fever associated neurotropic disease (YEL-AND) has an incidence of 1:8,000,000 doses.
It has a higher risk in young infants. The recovery rate is close to 100%.
Life-threatening reactions are extremely rare. Male: Female ratio is 2:1.
Persons over the age of 60 are more likely to have YEL-AND as well as other severe reactions.
I have had the effects, and possible side effects of Yellow Fever Vaccination explained to me. I am also
aware of the above information, and I hereby consent to undergo Yellow Fever Vaccination.
Decline / Refusal Waiver
I, have declined the following recommendation:
Comprehensive ConsultationMalaria Chemoprophyaxis For medical reasons I am unable to take the following International Travel Health and Vaccination Clinic Please answer the below questions to help us better understand your vaccination history For School Groups
Business/Organization/ Regular Travel Groups
Have you had your MMR (Measles/Mumps/Rubella) Have you had a tetanus/diphtheria shot in the last 10 years? Have you received your Grade 6 Hepatitis B vaccination? Have you had any travel vaccines previous to today? Have you received your Grade 9 vaccinations? (Tetanus/Diphtheria/pertussis and meningitis C) Other: ______________________________________ _________________________________________ _________________________________________ Have you had chicken pox as a childhood disease? Have you had any travel vaccines previous to today? Please list: _________________________________ ____________________________________________ ____________________________________________

Source: http://www.doctortravel.ca/uploads/file/pdfs/questionnaire.pdf