Microsoft word - new patient intake

Date:_______________________ Name:_______________________________________________________________________________ (if a minor, name of parent or guardian):___________________________________________________________________ Age Gender Primary Physician /address/phone Allergies to drugs, vaccinations, foods or environmental factors _______________________________________________________________________________ _______________________________________________________________________________ Current medications/hormones Do you have any of the following conditions? (PLEASE CIRCLE ALL THAT APPLY and ADD ANY OTHER CONDITIONS) ……….………………………………………… 2…………………….………………………………………… ………………………………………………… 4…………………………….………………………………. Do you take any of these medications (either prescription or over-the-counter)(PLEASE CIRCLE ALL THAT APPLY) Beta-blockers (e.g., Inderal, atenolol, propanolol, Corgard, nadolol, etc.) Calcium channel-blockers (verapamil, Verelan, Isoptin, Cardizem, diltiazem, Tiazac, etc.) Are you pregnant now, or do you anticipate becoming pregnant while you are staying abroad? When was your last menstrual period? Have you ever had a positive TB skin test? Yes / No Were you ever treated for tuberculosis? Yes / No When was your most recent TB skin test? ………………………………………………………………………………… C:\Users\OFFICE~1\AppData\Local\Temp\new patient intake.doc PREVIOUS TRAVEL HISTORY
Place of birth ________________________________
Citizenship(s) ___________________________________________________________________
If you were born outside the US, what year did you first arrive in the US? ___________________
Previous International travel – most recent first:
Prior immunizations (with dates) __________ __________ BCG (vaccine for tuberculosis) Have you had any adverse reactions to the above? __________ If so, indicate the vaccine and describe the reaction ______________________________________ If you were born after 1956, have you had measles, mumps or rubella? __________ (please circle which one) If not, have you been immunized against measles since 1980? __________________ Purpose of travel _____ 1. Business _____ 8. Pleasure _____ 9. Volunteer Agency _____10.Other _______________________________________________________ Type of travel (check choices) _____Guided _____Independent travel (fixed versus flexible itinerary) C:\Users\OFFICE~1\AppData\Local\Temp\new patient intake.doc Do you need any pre-travel physical exam forms completed? Yes / No Did you receive counseling / education prior to your other travels? __________________________ Check all that apply _____ Counseling 1. Primary MD 2. This Travel Clinic 3. Used Internet sources 4. Talked with friends who have traveled to area 5. Another Travel Clinic 6. Was in the military Planned international travel – begin with the country you are leaving from and end with the country you are returning to: (Please include all country layovers) _____10.Other _______________________________________________________ C:\Users\OFFICE~1\AppData\Local\Temp\new patient intake.doc _____Independent travel (fixed versus flexible itinerary) Are there any other factors about your anticipated travel that you would like us to know about? C:\Users\OFFICE~1\AppData\Local\Temp\new patient intake.doc

Source: http://www.fresnointltravelmed.com/new%20patient%20intake.pdf