The following is a list of what you should bring to your travel appointment TenderCare International Travel Clinic
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- Emery Greene
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1 Thank you for contacting TenderCare Clinic s INTERNATIONAL TRAVEL CLINIC about immunization needs for your upcoming trip. At your travel clinic appointment, we will present you with a health risk assessment, as well as important travel resources and then administer the appropriate immunizations required or recommended for your destination. We will also write any prescriptions that are pertinent to your travel plans. We also can provide the International Certificate of Vaccination (the Yellow Card ) and are a certified Yellow Fever Vaccination Center from the CDC, should Yellow Fever immunization be required for your destination. Please find attached initial paperwork for you. Fill out the information, to the best of your knowledge, and we will discuss anything you are uncertain of at the time of your consultation. Just return the completed form to us, as soon as possible. We will then review and research your destinations, vaccines with which you are current and your immunizations needs. We will then contact you to set up an appointment for your consultation, administration of necessary vaccines and any prescriptions you might need for your adventure. The following is a list of what you should bring to your travel appointment: Any immunization records you may have and/or Yellow Card. Any recommendations from a tour group, church, or cruise line associated with your international travel. Any other information you deem important to your health, medical conditions and treatment. TenderCare International Travel Clinic does not file for any insurance. We will, however, provide you with copies of necessary documentation for filing. *Please confirm via that you have received your Medical Questionnaire form. If you have any questions, please feel free to contact us at We look forward to serving your medical travel needs! Pam
2 TENDERCARE INTERNATIONAL TRAVEL CLINIC Wellness Center 1040 Park Drive Greensboro, GA (office) (fax) NAME ADDRESS BIRTHDATE GENDER ADDRESS LANGUAGE BEST SPOKEN: English Spanish Other MARITAL STATUS: SINGLE MARRIED WIDOWED DIVORCED SEPARATED RACE: Asian Native Hawaiian Black/African American White American Indian/Alaska Native Other Pacific Islander ETHNICITY: Hispanic or Latino Non-Hispanic or Latino ARE YOU A VETERAN? PHONE NUMBERS 1
3 TenderCare International Travel Clinic Medical Questionnaire Name Date Date of Birth Age Phone: Home Cell Work Immunization Questions: Yes No Describe Problem 1. Have you ever had a reaction or side effect from any shot? 2. Have you ever fainted from having your blood drawn or from a shot? 3. Female only: Are you pregnant? 4. Female only: Are you breastfeeding? 5. Female only: Might you become pregnant on this trip? 6. Do you have AIDS, or have close contact with anyone with any AIDSlike condition leukemia, or cancer? 7. Do you have a family history of immunodeficiency? 8. Have you had a fever in the past 48 hours? 9. Have you experienced a fever after a shot? If so please list the vaccine. 10. Are you allergic to eggs? 11. Do you have heart, kidney, or liver disease? 12. Have you had your thymus gland removed or a history of thymus disease, including myasthenia gravis, DiGeorge syndrome, thymoma? 2
4 General Medical Questions: Yes No Describe Problem 1. Do you have skin problems? 2. Do you have any eye conditions? 3. Do you have any stomach conditions including GERD? 4. Do you have any bowel conditions, such as diarrhea or constipation? 5. Have you had the disease hepatitis A or B or yellow jaundice? 6. Do you have trouble sleeping? 7. Do you take any medications regularly? If so please list the medication and condition that is being treated. 8. Do you have any medical condition(s) that you see a doctor for regularly? Any past conditions? 9. Do you have severe thrombocytopenia (low platelet count) or a blood clotting disorder? 10. Do you have a history of depression or other psychological/psychiatric problems? 11. Have you ever had a convulsion, seizure, or epilepsy? 12. Are you prone to motion sickness? 13. Who is your regular doctor? 14. Have you been treated for any type of cancer? What type and date? 3
5 Medication Questions: Yes No Problem 1. Are you allergic to any medications, foods or latex? If yes, what is the reaction? 2. Are you taking antibiotics? 3. Do you take steroids, prednisone, or cortisone for any reason? 4. Are you taking or will you be taking: (a) Pepto-Bismol to prevent Traveler s diarrhea? (b) Antacids? (c) Oral contraceptives? 5. Have you ever taken malaria medication? If so what kind? Any problems? Allergies Yes No Problem ARE YOU ALLERGIC TO: Gentamicin, streptomycin, neomycin, kanamycin Sulfites Aluminum or aluminum hydroxide Mercury or thimerosal Bee stings or have history of hives or urticaria Are you hypersensitive to gelatin? Are you hypersensitive to beef protein, soy, casein, lactose, phenol, or formaldehyde? Are you hypersensitive to soy? Are you hypersensitive to lactose? 4
6 Prior Immunizations Vaccine Yes No Unknown Date Hepatitis A (2 doses) Hepatitis B (3 doses) Hepatitis A/B combo (3 doses) Influenza Japanese Encephalitis Measles, Mumps Rubella (MMR) Meningococcal Pneumococcal Polio (3 doses either oral or injectable) Rabies Tetanus/Diptheria Tetanus, Diptheria/Pertussis Typhoid injectible Typhoid Oral Yellow Fever 5
7 TenderCare International Travel Clinic Medical Questionnaire Trip Information 1. Countries and cities you plan to visit (Please list in sequence): City & Country Arrival Date Departure Date Urban Rural How Long 2. Where will you be staying? (Please circle all that apply) Major resort hotels Small Hotels Hostel Staying with family or friends Camping Other Renting home/apt./condo Cruise ship 3. What is the purpose or type of activities you will be doing during your trip? (Please circle all that apply): Vacation Safari Will you be: Business Missionary Driving a car Relocation to the country Student Scuba diving Visiting friends and family Volunteer Agency Mountain Climbing Outdoor activities Adoption Bicycling Hiking Other 4. Who is traveling with you? Spouse Family member(s) Friend Tour Group Church Group Children (List age) How did you hear about our travel service? 6
International Travel Medical Questionnaire
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Patient Questionnaire of the Creighton Travel Clinic Health Risk Assessment Instrument [01 revised Feb. 2012] Page 1 of 6.
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Patient Questionnaire of the Creighton Travel Clinic Health Risk Assessment Instrument [01 revised Feb. 2012] Page 1 of 6 Would you, please...... fill in this form? Bring it with you when you come to the
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Patient Questionnaire of the CHI Health Clinic Travel Clinic Health Risk Assessment Instrument [Nov 2017] Page 1 of 6 Would you, please...... fill in this form? Bring it with you when you come to the Travel
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Name: Date of Birth: Address: City: State: Zip Code: Phone Number: Cell Phone: Work Number: Race: Primary Language: Secondary Language:
Address: Phone Number: Cell Phone: Work Number: Email: Last 4 of SS #: Patient Demographic Information: Gender: Male Female Marital Status Single Married Widowed Divorced Other: Ethnicity Hispanic or Latino
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BLUEGRASS DERMATOLOGY Patient Registration Form
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Is today's problem caused by: Auto Accident Workman's Compensation Slip and Fall Other. Address City/State/Zip Phone # (home) (cell)
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Patient Interview Form
Page 1 of 5 Physicians: D.F. Jackson, III, MD William D. McLaughlin, MD Robert P. Albares, MD Jeffrey J. Crittenden, MD Physicians: Samuel J. Tarwater, MD Travis J. Rutland, MD Ashwani Kapoor, MD Pathologist:
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