IMC New Traveler Form

To reduce the amount of time you spend in our office, fill out this form and return it to our office BEFORE SCHEDULING YOUR APPOINTMENT. "*" Fields Required.
Traveler Information
Referred by*

Physician Name / Other Source: 
First Name*
Last Name*
Home Address*
Address:
Suite:
Apt:
Box:
City:
Province / State:
Postal / Zip Code:
Home Phone* xxx-xxx-xxxx
Work Phone xxx-xxx-xxxx
Cell Phone xxx-xxx-xxxx
Email
Date of Birth* mm/dd/yyyy  Age:
Gender*
First Time IMC Client*
LAST IMC VISIT (MO/YR):
Employer
Cost Center / Job Number
Employment Status
Supervisor
Bill Services To*
Travel Information
Occupation*
Reason For Travel*
Destinations (City / Country)
Accomodations  City  Rural 
Frequent / Recurrent International Traveler
Departure Date mm/dd/yyyy
Length Of Stay / Rotation
Immunization History - Next to each immunization, write either the month/year inoculated, "+" if time unknown, "Hx" if you had the disease or "?" if unsure whether you were inoculated.
BCG (TB Prevention)*  Quick set:       
Chickenpox (Varicella)  Quick set:       
DPT/Tdap  Quick set:       
Hepatitis A - series of 2 shots  Quick set:       
Hepatitis B - series of 3 shots  Quick set:       
Influenza  Quick set:       
Japanese Encephalitis  Quick set:       
Measles  Quick set:       
Measles Mumps Rubella (MMR)  Quick set:       
Meningococcal-Menactra/ Menveo  Quick set:       
Meningococcal-Menomune  Quick set:       
Mumps  Quick set:       
Pneumococcal  Quick set:       
Polio/Injectable (IPV)  Quick set:       
Polio/Oral (OPV)  Quick set:       
Rabies  Quick set:       
Rubella (German Measles)  Quick set:       
Shingles/Herpes zoster (if born past 1965)  Quick set:       
Tetanus Toxoid  Quick set:       
Tetanus/Diphtheria (Td)  Quick set:       
Tdap (tetanus-diphtheria-activated pertussis)  Quick set:       
Tuberculin Skin Test (PPD)  Quick set:       
Typhoid Injectable (Typhim Vi)  Quick set:       
Typhoid Oral  Quick set:       
Yellow Fever  Quick set:       
Other immunizations
Unusual/adverse reactions to the above Vaccines
Have you had any immunizations in the last 30 days?
Physical exam / type required?
Medical History
Do you take any medications on a regular basis?
List medications and reasons for taking if applicable:
Allergies / Reactions
If yes:
Fainting/Dizziness Tendency With Needles
History of Active / Chronic
Asthma / Smoker* Yes  No 
Blood clotting tendency/pulmonary embolism/vein thrombosis* Yes  No 
Cancer* Yes  No 
Diabetes Mellitus* Yes  No 
Guillain-Barre Syndrome* Yes  No 
Glaucoma* Yes  No 
Heart/Lung Disease*  Yes   No 
Hypertension* Yes  No 
Immune Deficiency/Cancer* Yes  No 
Liver Disease* Yes  No 
Motion Sickness* Yes  No 
Neurological Disorders/History* Yes  No 
Shingles* Yes  No 
Surgery (recent)* Yes  No   If yes, what type:
Psychiatric Disorders/Depression* Yes  No 
Thymoma/Thymectomy/Splenectomy* Yes  No 
Other Active Chronic Issue
Do you have an International Certificate of Vaccination (yellow booklet)?
FORWARD IMC records to my personal physician
Communicate my medical information to me by  mail  fax  email 
Marital Status
Women Only:
Pregnant (or attempting)
Last menses/ period mm/dd/yyyy 
Breastfeeding
Medication Kits
Will you need a Travel Medicine Kit?
Will you need a Bloodborne Pathogen Protection Kit?
Will you need a Ebola Kit?
Ebola-modified kit?