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About
Who We Are
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Travel Health Clinic
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Administration & Departments
Community
Contact
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Hours of Operation
Online Booking
Book online now
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News
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204 822 4474
Traveler History Form
Traveler History Form
Step
1
of
5
20%
First Name
*
Last Name
*
Gender
Male
Female
Date of Birth
*
Month
Day
Year
Home Phone
*
Work Phone
Mobile Phone
Home Address
*
City
*
Province
*
Postal Code
*
Email
Primary care physician
Phone
MB Health (6 digit)
*
PHIN (9 digit)
*
Does your insurance cover:
Health care overseas?
Yes
No
Not Sure
Medical evacuation?
Yes
No
Not Sure
Travel Immunizations?
Yes
No
Not Sure
Birth country
TRAVEL PLANS
Please list each city and country, the arrival date, and duration in each place individually
*
Countries and cities in order of visit
Arrival Date
Duration (in days)
Purpose of trip (check all that apply)
Vacation
Education/research
Adoption
Visit friends or family
Missionary/volunteer/humanitarian relief
Work (urban, office-based, or conference)
Work (rural, outdoors, or in local community)
To obtain medical or dental care
Other
Other
Planned activities (list all)
This field is hidden when viewing the form
Planned activities (list all)
Will you be visiting areas that are:
Rural
Yes
No
Not sure
Urban
Yes
No
Not sure
Primitive or remote
Yes
No
Not sure
Ascending to high altitudes (8,000 ft or higher)? (does not include flight)
Yes
No
Not sure
Working with potential exposure to body fluids (e.g. medical or dental work)?
Yes
No
Not sure
Working with exposure to animals?
Yes
No
Not sure
Potentially having new sexual partners?
Yes
No
Not sure
Do you require a diving physical form completed?
Yes
No
Not Sure
Accommodations (check all that apply):
Resort/large hotel
Small hotel/guest house/B&B
Cruise ship
Private home (with locals)
Private home (with relatives)
Private home (expatriate or high-end)
Primitive camping
Up-scale camp/lodge
Dormitory/hostel
Other
Other Accomodations
Previous international travel
Year
Destination
HEALTH HISTORY
(Check all that apply)
Allergies
Egg
Latex
Gelatin
Yeast
Bees/wasps
Seasonal
Antibiotics (e.g., penicillin, sulfa)
Other medications
Side effects/reactions from previous medications (e.g., nausea, dizziness, stomach upset)
Other
Antibiotics (e.g., penicillin, sulfa)
Other medications
Other allergies
Side effects/reactions from previous medications (e.g., nausea, dizziness, stomach upset):
Immune system
Steroids by mouth within 3 months
Immune suppressive medications or treatments within last 3 months (e.g., radiation, cancer chemotherapy drugs, methotrexate, azathioprine, adalimumab, anakinra, etanercept, infliximab, leflunomide, rituximab)
Spleen removed
Thymus disease or thymectomy
Organ, bone marrow, stem cell transplant
Other
HIV/AIDS
Most recent CD4
Most recent CD4
Most recent viral load
Most recent viral load
Organ, bone marrow, stem cell transplant
Other immune system
Cardiovascular
Arrhythmia (rhythm disturbance considered significantly abnormal including atrial fibrillation, heart block)
Implanted pacemaker or automatic defibrillator
Heart attack
High cholesterol
High blood pressure
Stroke
Other
Other cardiovascular
Cancers/blood disorder
Coagulation disorder
History of cancer or blood disorder
Other
Other cancers/blood disorder
Kidneys
Dialysis
Kidney insufficiency
Other
Other kidneys
Lungs
Asthma
Emphysema/COPD
Other
Other lungs
Endocrine
Diabetes
Thyroid disease
Other
Other endocrine
Musculoskeletal
RA
Psoriatic arthritis
Other
Other musculoskeletal
GI
Crohn’s disease or ulcerative colitis
IBS
GERD
Chronic hepatitis
Cirrhosis or liver failure
Other
Other GI
Neurologic/psychiatric
Seizures or epilepsy
Anxiety /depression
History of Guillain-Barré
Other
Other neurologic/psychiatric
Skin
Psoriasis
Other
Other skin
OB/GYN
Pregnant
Breastfeeding
Possible pregnancy in next 3 months
Other
Other OB/GYN
VACCINATION HISTORY
(Please bring all vaccination records to your appointment.)
Have you received the following immunizations?
Hepatitis A
Yes
No
Not sure
When?
Hepatitis B
Yes
No
Not sure
When?
Meningococcal
Yes
No
Not sure
When?
Measles/Mumps/Rubella
Yes
No
Not sure
When?
Polio
Yes
No
Not sure
When?
Tetanus
Yes
No
Not sure
When?
Typhoid
Yes
No
Not sure
When?
Yellow Fever
Yes
No
Not sure
When?
Japanese Encephalitis
Yes
No
Not sure
When?
Influenza
Yes
No
Not sure
When?
Other
Have you ever had an adverse reaction to an immunization?
Yes
No
Explain:
CURRENT MEDICATIONS
Prescription medications: List all current prescription medications
Medication
Reason for use/medical condition
Non-prescription products: List current over-the-counter, herbal, homeopathic products, vitamins, supplements, etc.
Product
Reason for use/medical condition
QUESTIONS/CONCERNS
Additional questions or concerns about your travel:
Please note that there is a $25 cancellation fee for any missed appointments or if we are given less than 24 hours notice of cancellation. This fee must be paid prior to any further appointments being booked.
Please note: If you haven’t received a call within 10 days of submitting this form, you should call the clinic to inquire if your form was received.
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