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| Date of Birth |
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Nationality |
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| Address |
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| Telephone |
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Cell Phone |
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Primary Care Physician
Name:
Contact: |
Specialist
Name:
Contact: |
Primary Health Plan Information
Name of Plan:
Plan Number:
Contact Information: |
Evacuation Service Information
Name:
Plan Number:
Contact Information: |
| Blood Type/RH Factor: |
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Height/Weight |
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Allergies:
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Vaccination Record: DTP:
Hepatitis B: Haemophilus:
Influenza type b: Measles:
Polio:
Varicella: |
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Selective Vaccinations :
1.
2.
3.
4.
5. |
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| Past Exposure to Tropical Disease, Illness or Conditions? |
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| Current Medical Treatments? |
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| Chronic Conditions? |
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| Current or Recent Conditions? (Pregnancy, Flu, Injury) |
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| History of jaundice or hepatitis? |
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| History of Anxiety of Depression? |
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| Neurological Disorders? (Epilepsy, M.S.etc.) |
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| Cardiovascular Disorders? (Thrombosis, Pacemaker) |
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| Respiratory Conditions |
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Current Prescribed Drugs:
1.
2.
3.
4. |
Vitamins:
1.
2.
3.
4. |
Special Conditions:
Asthma:
Bee Stings:
Heart Conditions: |
| If lost, how will you obtain replacement drugs? |
Are the drugs that you are taking legal in the country that you intend to live in or visit? |
What amount of prescription drugs or vitamins are you legally allowed carrying into the country?
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| Do you have a valid copy or new prescription for the first refill?
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Will environmental conditions affect the prescriptions medicines? (Heat, Sun, Humidity, Altitude?) |
Will local foods or drink effect the prescription medicines?
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| Physician Identified in country to help? |
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| Hospital Identified in country to help? |
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Country |
Town |
Rural Area |
Dates |
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Yes No |
From:
To: |
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Yes No |
From:
To: |
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Yes No |
From:
To: |
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Yes No |
From:
To: |
| Special Activities |
Accommodation:
Camping
Bivouac |
Sports:
Diving & Snorkeling?
Skiing, Snow & Water?
High Altitude?
Hunting?
Cycling?
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Voluntary Work :
Agriculture?
Water?
Healthcare? |
- Is a HIV test required for travellers or short term visits? Y____ N_____
- Is a HIV test required for long term stay / residency? Y_____ N______
- Does the country require certified results? Does the consulates / embassy has specific medical documents? Does the test need to be completed prior to entry?
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| 1. Routine Vaccination |
Diphtheria / Tetanus / Pertussis (DTP)
Hepatitis B (HBV)
Haemophilus Influenza type b (Hib)
Measles (MMR)
Poliomyelitis (OPV or IPV)
aricella (for persons who never had chickenpox) |
| 2. Selective Vaccinations |
Cholera
Influenza (Recommended for adults 65 years or older, or other high risk individuals)
Hepatitis A (HAV)
Japanese Encephalitis
Lyme Disese
Meningococcal Disease
Pneumococcal Disease
Rabies
Tick-borne Encephalitis
Tuberculosis (BCG)
Typhoid Fever
Yellow fever (for individual protection) |
| 3. Mandatory Vaccination |
Yellow Fever (For protection of vulnerable countries)
Meningococcal Disease (Required by Saudi Arabia for pilgrims visiting Mecca annually (Hajj) or at anytime (Umrah) |
| Source: UN, WHO |
| Accidents |
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| Infectious Diseases |
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| Environmental Risks |
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| Environmental Factors |
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| Food Illness |
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| Violence |
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| Instructions : Complete this form with your Physician. It is recommended that you schedule your pre-departure examination with your Physician at least 10 to 12 weeks prior to travel. This will allow time to fulfill immunization requirements. |
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