Chaffee County Public Health
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1 Chaffee County Public Health 448 E. 1st Street Suite 137 Salida, CO Phone: Fax: Yellow Fever Vaccine Questionnaire Name: DOB: / / 1. Is this the first Yellow Fever Vaccine that you have received in your lifetime? a. if, when was your last: b. Other eplanation: 2. Have you experienced any side effects from previous Yellow Fever Vaccinations? a. if, please explain: 3. Do you or have you had your spleen removed, an organ transplant, leukemia, lymphoma, cancer, other malignancies &/or HIV/AIDS? 4. Have you been medically treated with chemotherapy or radiation therapy for cancer within the last three months? 5. Have you been on steriod theapy within the past month? 6. History of thymus disease, thymoma, Myasthenia Gravis and/or DiGeorge Syndrome? 7. Do you have a hypersensitivity/allegery to eggs, chicken, or gelatin? 8. Women Only: a. Are you pregnant or do you plan to become pregnant in the next month? b. Are you breastfeeding or do you plan to breastfeed in the next month? 9. Have you received a live vaccine within the past 4 weeks: (MMR, Varicella, Zostavax, and/or Flu Mist)? 10. Have you read the CDC's Vaccine Information Statement for the Yellow Fever Vaccine? A Yellow Fever Vaccine may be required on some visa applications, or to participate in some travel abroad programs. The Yellow Fever Vaccine is the ONLY vaccine required for entry by foreign governments at this time. This requirement is intended to keep their countries free of disease, T to keep you healthy. All other vaccines may be recommended, but will not be required for entry into a foreign country. Client Signature: Date: / /
2 **** FOR OFFICE USE ONLY**** TES: Nurse Signature: Date: / / Vaccine Recommendation: [ ] [ ] M.D. Consult: [ ] [ ] Recommendation from Medical Director: Medical Director Signature: Date: / /
3 Chaffee County Public Health 448 E. 1st Street Suite 137 Salida, CO Phone: Fax: Patient Information: Travel Pre-Immunization Questionnaire Last Name: First Name: Phone #: Date of Birth: / / Age: Gender: M F Weight (if child): Street Address: City/Town: State: Zip Code: Place of Birth (Country or state in US): Primary Language Spoken/Read: Occupation: Are you a person of Native American or Alaskan Native descent? Please List Medications: Name and Phone Number of preferred pharmacy: Health Questions: (if an answer is yes, please provide additional details on the space provided) 1. Are you sick today? 2. Do you have any allergies to food, medications, environment, latex? 3. Have you ever had a serious reaction to a vaccination? 4. Do you have any chronic conditions such as asthma, cardiac, respiratory, renal, musculockeletal, gastrointestinal, metabolic, or blood disorder, etc.? 5. Do you have, or had you had, cancer, leukemia, lymphoma, other malignancies, HIV/AIDS, complement, deficiency, your spleen removed, an organ transplant, immuyne system problem, thymus disease, Thymoma, Myasthenia Gravis, DiGeorge Syndrome, or any other long-term problems? 6. Have you had major surgery in the past 3 years? 7. Do you have a seizure disorder? 8. Do you live or work closely with anyone with an immune disorder?
4 9. Are you taking steroid, (cortisone/prednisone) or have you been on steroid therapy within the past month? Have you been treated with anticancer drugs (chemotherapy) or had radiation treatment within the last 3 months? Are you receiving antiviral drugs? 10. Are you taking aspirin or products containing aspirin? 11. In the past year, have you received a blood transfusion or had a gamma globulin injection? 12. Are you pregnant, trying to become pregnant, sexually active and not on birth control, or nursing a baby at this time? 13. Have you had any vaccines in the past 4 weeks? 14. Do you use tobacco products? 15. Do you currently have or had a history of: Antidepressant or psychiatric medication use: Depression, anxiety, panic attacks Psoriasis Heartburn, reflux, other intestinal issues History of Altitude Illness Achilles Tenson rupture or tendonitis Do you drink alcohol regularly Do you use recreational drugs Have you ever had Hepatitis Travel and Destination Information: Date of Departure from Home: Return Date/Length of Trip: Have you traveled internationally in the past? Where? Do you intend to travel frequently in the future? Maybe Itinerary: Please give ALL countries to be visited, including stopovers, in the order (if possible) to be visited: Destination: (check all that apply) Urban Rural Remote High Altitude Beach Is this a fixed itinerary? Not sure Purpose of Trip?: (check all that apply) Vacation Medical Care Business Education Adoption Volunteer/Humanitarian Visiting Friends and/or Relatives Long-Stay Traveler Organized Tour? Partly Explain:
5 Accommodations: (check all that apply) Hotel Hostel Rented House/Apt Camping Staying with Locals/Family/Friends Cruise Ship/Boat Will you be traveling alone? if no, explain: Planned Activities: (check all that apply) Air Travel Biking Hiking Snorkeling Swimming Rafting Boating SCUBA diving Climbing/Trekking Cave/Spelunking Public Transport: (bus, train, ect.) Other: Please Explain: Contact with Animals? Explain: Visting schools, hospitals, orphanages? Health Care Worker Occupational Exposure Other: Have you obtained travel medicine evacuation insurance? Do you consider yourself a risk-taker? Is there any other information about your trip, whether related to destinations or your activities while there, that you feel I should know in helping you determining safety and protection measures? Please Explain: Traveler's Stop Here For Nurse Only: Nurse Signature: Date: / /
6 IMMUNIZATION CONSENT FORM and HIPPA ACKWLEDGEMENT I authorize the vaccine information to be entered into the Colorado Immunization Information System (CIIS), under the Colorado Immunization Act. I authorize the release of information to or from: a health care provider, clinic, hospital, public health agency, school, and the CIIS. I understand the information will only be released for the specifici purpose of verifying immunization status. This authorization will remain valid for five years from the signature date. I can rescind (take back) this authorization at any time by requesting this of Chaffee County Public Health of this request, in writing. I realize staff may suggest certain vaccines that I am opposed to and I have a right to refuse them. I have read or have had explained to me the information in the Vaccine Information Sheets (VIS) for each vaccine I am receiving. I have had the chance to ask questions that were answered to my satisfaction. I believe I understand the benefits and risks associated withe the vaccines and have agreed to the vaccinations. I have given the most accurate and detailed information about my health in the questionnaire above (and for travelers, about my trip dates, and destinations) and give consent to the immunization services by Chaffee County Public Health. I have been advised that it is best to stay seated in the immunization or waiting room for 15 minuetes after receiving vaccines in case of allergic or adverse reaction. I authorize Chaffee County Public Health to share the necesarry information with my insurance company to try to receive payment, if it is thought that the vaccines are covered by my insurance, and am aware that payment from that insurance carrier may be sent directly to Chaffee County Public Health. I understand that I am finacially responsible for all charges wheter covered by insurance or not. I also understand that balances are required to be paid at the time of service. I acknowledge that I have been offered a copy of Chaffee County Public Health Health Notice of Privacy Practices. Date: / / Signature of Patient/Parent/Guardian Relationship to Minor Date: / / Signature of Chaffee County Public Health Staff
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To Our Patients: As you know if you have ever checked into a hotel or rental car, the first thing you are asked for is a credit card, which is imprinted and later used to pay your bill. This is an advantage
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501 Islington Street, Suite 2B Portsmouth, NH 03801 P: 603-610-8882 F: 603-463-0943 New Patient Intake Form Personal Information Today s Date Name Age DOB: Phone: H ( ) W ( ) Cell ( ) Preferred Home Work
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Dear Parent/Guardian: Margaret Mary Health (MMH) has agreed to give the flu (influenza) vaccine to the students at your child s school on October. 30th MMH highly recommends the FluMist vaccine which is
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1227 E. 9th Street Edmond, OK 73034 Phone: (405) 475-0100 Fax: (405) 475-9275 https://susandimickmd.com Welcome to Dr. Dimick s Office. We appreciate the opportunity to provide your health care needs.
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