* Required Fields
Date:07/09/2010
*Health Insurance #:
Vaccines, medications and other travel recommendations will be tailored to suit your needs based on your responses.
*First Name:
*Last Name:
Middle Name:
*Date of Birth (DD/MM/YYYY):
*Gender: Male Female
*Address:
*City:
*Province:
*Postal Code:
*Phone (Home):
Cell:
Email:
*Health Card #:
*Version Code:
*Expiry Date:
Business Phone:
Medical Allergies:
Weight (*if under 18 years):
lbs kg
*Country of Birth:
If not in Canada, at what age did you leave your country of birth?
*Company:
*Job Title:
*Emergency contact:
*Phone:
*Relationship to you:
(This information will NOT be shared with your employer.)
*Do you currently have a fever or an active infection? YES NO
Do you have (or have you had) any of the following medical conditions? (* At least one or check "Free from any Medical Condition")
Chronic or significant medical condition (specify)
Thymus disease
1.
Inflammatory bowel disease
2.
Diabetes
3.
Respiratory (lung) conditions
4.
Liver disease
Seizures or convuisions
Immunosuppression/impaired immune system
Heart disease
Coagulation disorder
Depression
Anxiety
Psoriaris
Other
Free from any Medical Condition
Are you taking any of the following medications? (* At least one or check "No medication")
Anticonvulsants
Immunosuppressive drugs
Antidepressants
Anti-Viral medication (HIV, other)
Anticoagulant/Warfarin/Coumadin
Steroids (prednisone)
Chemotherapy
No medication
Are you allergic to any of the following? (* At least one or check "No allergy")
Eggs (describe reaction):
Sulfa, Sulfamycin, Bactrim, Septra
Food (describe reaction):
Penicillin
Wasp/Insect bites
Tetracyclines
Latex
Formaldehyde or Phenol
Thimerosal or Aluminum
Neomycin
No allergy
Are you pregnant? Yes # of weeks No
Are you planning to become pregnant within 3 months? Yes No
Are you breastfeeding? Yes No
Do you have any concern(s) regarding your period while on this trip? Yes No
*How would you be travelling? By air Cruise Land Sea
*ITENERARY Departure date (DD/MM/YYYY):
*Duration of trip: days weeks months
Please, list all countries and regions you will visit (including stop over) during your trip: (* At least one)
Countries to be visited
Urban areas/Duration
Rural areas/Duration
Purpose of trip: (* At least one)
Pleasure/holiday
Education/study/summer camp
Business (specify type of work)
Visiting family/friends
Volunteer work
Adoption
Religious visit
Where will you be staying: (* At least one)
1st class hotel, resorts or cruise ship
Camping
Inns/B&B
Family/Friends
Possible activities: (* At least one)
Healthcare activities
Wilderness activities/extreme sports
Safari
Volunteer/humanitarian activities
High altitude activities/climbing
Jogging, running, bicycling
Activities involving contact with animals
Rafting/water sports
Other:
Veterinary activities
Underwater diving
I have not had any vaccinations in the past 10 years
VACCINE
Date of Last Dose
Cholera (Dukoral)
MMR
DT (Diphteria/Tetanus)
Polio
DTaP (Adacel)
Pneumococcal
DTP (Dipht./Tet./Polio)
Rabies
Hepatitis A
TBE vaccine
Hepatitis B
Typhoid fever
Hepatitis A&B combo
Yellow fever
Hepatitis A/Typhoid combo
Zoster (shingles)
HPV (Garbasil, Cervarix)
Influenza
Japanese encephalitis
Mantoux test
Meningitis
Have you ever had an adverse reaction to a vaccine?Please specify:
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 occure.
*Initials of the patient:
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.
Please select your travel destination region:
