Microsoft word - travel health questionnaire new toronto _3_.doc

Travel Health Clinic
You must remain in the clinic for 20 minutes following any vaccination.

Date: ___ / ___ /_____ (DD/MM/YYYY) Chart #: _____________ Health insurance #:____________________
PATIENT INFORMATION (To be completed by the traveller)
Vaccines, medications and other travel recommendations will be tailored to suit your needs based on your responses.
Gender:  Male  Female Date of birth: ____ / ____ /________ (DD/MM/YYYY) Last name: ________________________________________ First name: __________________________________________ Street: ____________________________________________ City: _________________________________ Province: ______ Country: __________________ Postal code: __________________ Phone (Home): _______________________ (Work): ________________________ (Cell): ____________________________ E-mail: ____________________@__________________________ Weight (if under 18 yrs): _________ lbs  kg In what country were you born? _____________________ If not in Canada, at what age did you leave your country of birth? _______ Company: __________________________________ Job title:__________________________________________________ Emergency contact: ________________________ Phone: ____________________ Relationship to you: __________________
MEDICAL INFORMATION (This information will NOT be shared with your employer.)
Do you have (or have you had) any of the following medical conditions?
 No medical condition
 Chronic or significant medical condition (specify) i ____________________ ii ______________________ iii ___________________ iv ______________________  Immunodeficiency disorder (i.e.: cancer treatment, HIV infection, high doses of steroids, graft)  Other: ___________________________________  Anxiety
Do you take any medication?
 No medication
 I do not have the name, but I take medication for the following condition or of this type: ______________  Contraceptive: ___________________________ _________________________________________  List: ___________________________________ _________________________________________ _________________________________________  Anticoagulant / Warfarin / Coumadin _________________________________________ _________________________________________ _________________________________________ Do you have allergies?
 No
allergies
 Eggs (describe reaction):_________________________  Food (describe reaction): __________________  Other: _________________________________ Do you currently have a fever or an active infection? Yes  No 
WOMEN ONLY Do you have any concern(s) regarding your period while on this trip?
Yes  No 
Are you pregnant?
Yes  - # of weeks: ______________________
No  - Are you planning to become pregnant within 3 months? Yes  No 
Are you breastfeeding? Yes  No 

Travel Health Clinic

ITINERARY Departure date: _____ / _____ /______ (DD/MM/YYYY) Duration of trip: ________________________
Please, list all countries and regions you will visit (including stop overs) during your trip
Countries
visited Urban
areas/Duration Rural
areas/Duration
Purpose of trip:
Where will you be staying?
 1st class hotel, resorts or cruise ship
Possible activities:
 Healthcare activities
 Activities involving contact with animals IMMUNIZATION
 I have not had any vaccinations in the past 10 years
Have you ever had an adverse reaction to a vaccine?
Please specify: ____________________________________________________________________________________
I declare that all the information provided on this form is accurate to the best of my knowledge and I understand that any false information could be detrimental to my health. By the present document, I herein authorize Medisys, Travel Health Clinic and their medical and para-medical staff to proceed with the immunizations required for: the prevention of infections representing a risk for my health and/or I acknowledge that Medisys Travel Clinic is a private clinic, and as such, the costs associated with my consultation and associated services (nurse and/or physician) as well as all vaccines received and material required for vaccination are my responsibility unless assumed via direct contractual agreement within the context of an employer-mandated foreign medical examination. Signature: ________________________________ Date: ___ / ___ /______ (DD/MM/YYYY) Note: Most vaccines are generally well tolerated; however, you may experience some soreness, redness and swelling at the injection site. Other adverse reactions may include headaches, fever, fatigue, and muscle pain. As with any vaccine, an allergic reaction or anaphylactic response could occur.

Source: https://www.medisys.ca/Documents/travel-health/th-form-to.pdf