Travel clinic form.indd

10060 Regency Circle
(402) 354-1530
You may fax completed form back to (402) 354-1535
Today’s Date: ______/ ______/ ______ (MM/DD/Year) Last Name: _______________________________________ First Name:___________________________________________ Address: ______________________________________________________________________________________________ City: ____________________________________________ State: ___________________________ Zip: _________________ Date of Birth: ______/ ______/ ______ Gender: Home Phone #: ___________________________________ Work Phone #: _________________________________________ Cell Phone #: _______________________________ E-mail address: ______________________________________________ Emergency Contact: _______________________________ Contact’s Phone Number: ________________________________ Primary Care Physician: ____________________________ Physician’s Phone Number: _______________________________ Travel Specifi cs:
School/Company’s Name: ___________________________________ Other: ______________________________________ 2. What will you be doing on this trip? _______________________________________________________________________3. Does your program require completion of a medical form by a practitioner? 4. Are you currently enrolled in a health insurance plan that covers you while you are overseas? Unsure No Yes If yes, what insurance plan do you have? ______________________________________ 5. Departure Date from the United States:______________ 6. Return Date to the United States:_________________________ Countries and Cities to be visited in order of visits 7. Have you traveled outside the US before? Yes No If yes, where and when? _________________________________________________________________________________8. Will you be visiting only urban areas? Yes No If no, explain: _______________________________________________ Staying only in hotels? Yes No If no, explain: ________________________________________________________ V Ascending to high altitudes (>7,000 feet or 2,300 meters) in the mountains? Working in a medical or dental fi eld with exposure to blood/other body fl uids? Potentially having sexual contact with new partners? Immunizations:
1. Were you born in the United States? Yes No If no, where: ______________________________________________
2. Have you completed the following immunizations?
Medical History:
1. Are you taking steroids, receiving radiation therapy, or other immunosuppressive chemotherapy?
If yes, what?___________________________________________________________________ 2. Please list your current prescription medications and the medical conditions being treated. (include birth control pills) 3. Please list regulary used non-prescription medications (over-the-counter, herbal, homeopathic, vitamins, etc.)Regularly Used Non-Presciption Medications 4. Have you been told you have any of the following medical conditions (check all that apply)? Other: ___________________________________________________________________________________________ Allergies:
1. Have you had a reaction to any of the following? (please check all that apply)
Pyrimethamine Antibiotics (e.g., Neomycin, Streptomycin) Thimerosal (preservative in contact lens solution) Quinines (Chloroquine [Aralen], Mefl oquine [Lariam] Hydroxychloroquine [Plaquenil], or Primaquine) Tetracyclines (Doxycycline, Minocin, Minocycline, Acromycin, Sumycin) 2. Do you have any food or drug allergies not listed above? If so, please list:______________________________________ For Women Only:
a. When was your last menstrual period? ______________________________
b. Are you, or could you possibly be, pregnant?
Questions or Concerns: Please list additional questions or concerns that you might have regarding your travel. (i.e.
dealing with motion sickness, altitude sickness, etc.) ________________________________________________________
How did you hear about us?
Word of Mouth, if so who: ________________________
Internet, if so what website________________________ Marketing Materials: _____________________________
Referral from your physician – Dr: ___________________ Other, please explain: ____________________________
By signing below, I acknowledge that the information contained in this document is accurate and complete to the bestof my knowledge. If medications will be prescribed to me, I understand that the clinic is operating under a drug therapymanagement protocol with the medical director, and I consent to be treated following this protocol.
X______________________________________________________ ___________________________________Signature BELOW THIS LINE IS FOR OFFICE USE ONLY:Date and time of appointment: ______/ ______/______ at ______ am pm



Pro and antibiotic in sequence perform well in broiler diet A lot is known about the use of antibiotics as growth chicks were housed in an electric batterybrooder. Feed and water were provided ad promoters in broiler feed, but how do they perform in libitum throughout the experimental peri-od of seven weeks. The main ingredients of comparison to probiotics, and can they be combi


Lipitor and Paroxetine patent decisions handed down by the UK High Court and House of Lords - by Ralph Cox of Stringer Saul LLP In the Lipitor case, Ranbaxy v Warner-Lambert ([2005] EWHC 2142 (Pat)) the High Court held that a claim to a racemic mixture is infringed by use of the pharmaceutically active enantiomer alone. The Court also commented on the drawbacks to the European Patent Office’s p

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