Hartzells.com

300 American Street, Catasauqua, PA 18032610-264-5471 or 1-800-325-6856Email: [email protected] Today’s Date: / / Date of Birth: / / ☐ Male ☐ Female TRAVEL SPECIFICS
Purpose of trip: ☐ School related study/ work What school? ☐ ☐ Visiting ONLY urban areas? If no, explain: ☐ ☐ Staying ONLY in hotels? If no, explain: ☐ ☐ Visiting friends and family?☐ ☐ Ascending to high altitudes (>7,000ft or 2,300 meters) in the mountains? ☐ ☐ Working in the medical or dental field with exposure to Does your program require the completion of a medical form by a ☐ ☐ Working with exposure to animals? ☐ ☐ Potentially having sex with new partners? Are you currently enrolled in a health insurance plan that covers you while overseas?. ☐ Yes ☐ No ALLERGIES
What insurance coverage do you currently have? ☐ No known DRUG allergies ☐ No known FOOD allergies Have you had an allergic reaction to any of the following? (please check all Departure: Date and U.S. City departing from United States: Return: Date and U.S. City entering upon return date to United States: (wheezing, rash, trouble breathing, etc.) If you have a detailed itinerary, please attach it so that we can review the full details ☐ Antibiotics (e.g. Neomycin, Streptomycin)☐ Sulfa drugs (e.g. Bactrim, Septra, Gantrisin)☐ Chrysanthemums☐ Pyrimethamine☐ Quinines (Chloroquine [Aralen], Mefloquine [Lariam], Hydroxychloroquine [Plaquenil], Primaquine) A. Have you travelled outside of the United States before? ☐ Yes ☐ No 300 American Street, Catasauqua, PA 18032610-264-5471 or 1-800-325-6856Email: [email protected] MEDICAL HISTORY
Are you using steroids, receiving radiation therapy, or other immunosuppressive chemotherapy? ☐ Yes ☐ No List your current prescription medications and medical condition (include birth control pills). If you need additional space, please attach a separate List regularly used non-prescription medications (over-the-counter, herbals, vitamins, homeopathic). If you need additional space, please attach a separate sheet to this form: Have you been told that you have any of the following medical conditions? (list any others on the back) 300 American Street, Catasauqua, PA 18032610-264-5471 or 1-800-325-6856Email: [email protected] For Women Only:
Last normal menstrual period:
Are you or could you be pregnant? ☐ Yes ☐ No
Are you currently breast-feeding or will you be on the trip? ☐ Yes ☐ No
Please attach a current vaccine record to this sheet. If you do not have an updated vaccination record, please complete a Release of Records
form so that we may contact your other health care providers to obtain the necessary information. Vaccine record attached: ☐ Yes ☐ No
Are there any specific concerns or questions you have about your travel that you would like answered during the consultation? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________(patient name), grant Hartzell’s Pharmacy permission to contact my physician to obtain any necessary health information that would be relevant for this travel health consultation. I acknowledge that I have completed this form to the best of my abilities. I am aware that the Travel Health Consultation will be based on the information provided herein. I am aware that a non-refundable deposit of $30.00 (CPT 99605) will be charged up front and applied to the first 15 minutes of the consultation.

Source: http://www.hartzells.com/Assets/thc_intake_sheet.pdf