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PrimeCare of Michigan > Travel Medicine Request for Consultation

Travel Medicine Request for Consultation

Thank you for choosing us for your travel medicine consultation. A member of our team will call you to schedule your appointment once we have reviewed this form.

Traveler's Full Name

Date of birth

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Departure Date

MM slash DD slash YYYY

Return Date

MM slash DD slash YYYY

List all the countries and cities on your itenerary in the order you will be visiting:

Visiting areas outside major cities?

Yes

No

Please bring BOTH your childhood and adult immunization/yellow fever immunization record AND current list of medications to the first travel appointment.

Have you traveled outside the US/Canada in the past?

Yes

No

Which countries outside the US/ Canada have you traveled to?

Did you encounter any difficulties?

Travelers' Diarrhea

Malaria

Air sickness

Infection (other than common cold)

Mountain (altitude) sickness

Jet lag

Other please explain

Other please explain

Personal Health History (please check all that apply)

Immune disorders

Recent prescription for steroids

Hepatitis A

Hepatitis B

Hepatitis C

Any chronic illness like asthma, diabetes, seizure disorder, liver or kidney disease, cancer, high blood pressure, splenectomy, bleeding disorders, bypass surgery, stomach surgery, etc...

Please explain your chronic conditions

Have you ever had a TB test?

Yes

No

Was there a reaction?

Yes

No

Did you have a chest x-ray after the positive tb test?

Yes

No

What was the findings of the chest xray?

Do you have allergies to the following?

Thimersol

Insects

Neomycin

Yeast

Eggs

Do you have any special requests?

Travel Medicine Planner

Information provided by patients to help us set up a travel medicine consultation.

Thank you for choosing us for your travel medicine consultation. A member of our team will call you to schedule your appointment once we have reviewed this form.

Traveler's Full Name

Date of birth

MM slash DD slash YYYY

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Departure Date

MM slash DD slash YYYY

Return Date

MM slash DD slash YYYY

List all the countries and cities on your itenerary in the order you will be visiting:

Visiting areas outside major cities?

Yes

No

Please bring BOTH your childhood and adult immunization/yellow fever immunization record AND current list of medications to the first travel appointment.

Have you traveled outside the US/Canada in the past?

Yes

No

Which countries outside the US/ Canada have you traveled to?

Did you encounter any difficulties?

Travelers' Diarrhea

Malaria

Air sickness

Infection (other than common cold)

Mountain (altitude) sickness

Jet lag

Other please explain

Other please explain

Personal Health History (please check all that apply)

Immune disorders

Recent prescription for steroids

Hepatitis A

Hepatitis B

Hepatitis C

Any chronic illness like asthma, diabetes, seizure disorder, liver or kidney disease, cancer, high blood pressure, splenectomy, bleeding disorders, bypass surgery, stomach surgery, etc...

Please explain your chronic conditions

Have you ever had a TB test?

Yes

No

Was there a reaction?

Yes

No

Did you have a chest x-ray after the positive tb test?

Yes

No

What was the findings of the chest xray?

Do you have allergies to the following?

Thimersol

Insects

Neomycin

Yeast

Eggs

Do you have any special requests?

We will see you in our office, urgent care and in the hospital.

We cannot wait to meet you!

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