Travel Form

Traveler's Name

Date of Birth

Phone Number

Email Address

Street Address

Address Line 2

City

State

Zip Code

Primary Care Provider

Check Any Chronic Medical Conditions Check Any Chronic Medical Conditions No Chronic Conditions Sicle cell disease or other anemia Hepatitis or other liver disease Splenectomy (spleen removed) Seizure disorder/epilepsy Depression AIDS/HIV Heart disease Asthma/COPD Urinary Problems Pregnant/nursing or planning Diabetes Duodenal or gastric ulcer Psychiatric disorder Lupus Kidney disease Glaucoma Migraines Thyroid Cancer Other autoimmune disease Other conditions

Current Medications (list all prescription, over-the-counter medications, and supplements)

Allergies (list all medication, food and insect allergies)

Do you carry epinephrine for anaphylactic emergencies from insect bites, food allergies or other causes? Do you carry epinephrine for anaphylactic emergencies from insect bites, food allergies or other causes? Yes No

Check any immunizations you have received in the past. Check any immunizations you have received in the past. Chicken Pox Influenza (flu) Meningococcal Tetanus/Diptheria MMR (measles, mumps, rubella) Human Papilloma Virus (HPV) Hepatitis B Japanese Encephalitis Shingles Pneumococcal Tetanus/Diphtheria/Pertussis Yellow Fever Polio Hepatitis A Typhoid Rabies

Have you ever experienced any of the following? Have you ever experienced any of the following? Malaria Infection Traveler's diarrhea Altitude sickness Motion sickness

Do you travel frequently to foreign countries? Do you travel frequently to foreign countries? Yes No

List dates and locations of recent foreign travel

Itinerary: List, in order, countries and cities you plan on visiting including layover countries even if you aren't planning on leaving the airport. Indicate the date of arrival and departure of each location.

Indicate the type of travel for your trip. Indicate the type of travel for your trip. Affluent tourism/business/professional travel (hotels in urban or resort areas, hostels, minimum rural travel) Staying with friends/family/others in rural house or village Rural or backcountry camping/backpacking/hiking/mountaineering

Check each activity that may be applicable to your trip. Check each activity that may be applicable to your trip. Nurse, physician, or other allied health personnel Missionary Rural/Adventure travel Animal Handler/Veterinarian

Briefly describe the purpose of your trip and any other information relevant to your travels.

I understand the risks and benefits of vaccines, and I authorize the pharmacist at Schaffner Pharmacy to administer them to me. I do not hold the authorizing physician or pharmacist responsible for any adverse reactions. I understand that it is recommended that I remain at the pharmacy for 10-15 minutes after receiving vaccinations in case of severe reactions. A consultation fee will be charged, as well as the cost of any medications and/or vaccines you may be prescribed. We will attempt to bill your insurance, but if your insurance does not cover the vaccines/medications you will be billed for their cost. We will always contact you with the total costs so that you can decide the best course of action. I understand the risks and benefits of vaccines, and I authorize the pharmacist at Schaffner Pharmacy to administer them to me. I do not hold the authorizing physician or pharmacist responsible for any adverse reactions. I understand that it is recommended that I remain at the pharmacy for 10-15 minutes after receiving vaccinations in case of severe reactions. A consultation fee will be charged, as well as the cost of any medications and/or vaccines you may be prescribed. We will attempt to bill your insurance, but if your insurance does not cover the vaccines/medications you will be billed for their cost. We will always contact you with the total costs so that you can decide the best course of action. I understand the above statement

Electronic Signature

Date