Pre-travel assessment form - Clarks Pharmasave

1. Personal Details

Name (required)

Health Card Number (required)

Primary Care Provider

Email address (required)

Date of Birth (required)

Gender (required)

Male

Female

Weight ( please add kg or lbs beside your weight ) (required)

Telephone (required)

Full Address (required)

2. Personal Medical History

Are you currently pregnant or breastfeeding?

YES

Have you received any vaccinations within the past 28 days?

YES

Have you had a fever within the last 7 days?

YES

Do you have a personal history of HIV/AIDS, Hepatitis B, Hepatitis C, or other blood-borne illness?

YES

Have you recently undergone radiation or chemotherapy or used immunosuppressive drug therapies including Humira, Remicade, Enbrel or high dose corticosteroids?

YES

Do you currently have any medical conditions leading to suppressed immune function, ie. HIV infection, leukemia, lymphoma, thymic disease, generalized malignancy?

YES

Are you aware of any existing or past issues with your liver or kidneys?

YES

Do you have a personal history of blood clots?

YES

Do you have any known allergies?

YES

Notes regarding any positive responses to above questions:

3. Medication Record

The pharmacist will perform a MedsCheck with all travellers prior to preparing the final travel plan. Please bring all prescription and non-prescription items with you to your consultation

4. Vaccination History (bring record with you to appointment)

Abbreviations: HPV - human papillomavirus; MMR - measles, mumps, rubella

5. Travel Itinerary

Please complete in chronological order of travel as it may influence which vaccines are required. List all towns, villages, cities, etc. to be visited as vaccination requirements may differ within the same country.

1. Location (please be specific)

Accommodations

Date of Arrival

Date of Departure

2. Location (please be specific)

Accommodations

Date of Arrival

Date of Departure

3. Location (please be specific)

Accommodations

Date of Arrival

Date of Departure

4. Location (please be specific)

Accommodations

Date of Arrival

Date of Departure

5. Location (please be specific)

Accommodations

Date of Arrival

Date of Departure

6. Location (please be specific)

Accommodations

Date of Arrival

Date of Departure

7. Location (please be specific)

Accommodations

Date of Arrival

Date of Departure

8. Location (please be specific)

Accommodations

Date of Arrival

Date of Departure

9. Location (please be specific)

Accommodations

Date of Arrival

Date of Departure

6. Trip Details

What is the reason for travel?

Pleasure/Relaxation

Business

Healthcare (providing)

Healthcare (receiving)

Sport/Recreation

Aid/Relief

Adventure/Exploration

Other: (please provide details)

What is your level of travel experience?

Within Canada, never out of country

Within North America, never overseas

Travelled overseas, never to destination

Travelled to destination

Who are you travelling with?

Solo

Family

Friends

Young children

Seniors

Group (please specify)

Group (please include details )

Other (please provide details)

Who organized the trip?

Self-organized

Friend

Employer

Travel Agent

Charitable organization

Church

Other (please provide details)

What is the nature of the accommodations?

All-inclusive resort

Personal residence

Premium hotel

Cruise ship

Budget hotel

Car camping

Hostel

Backpacking/trekking

Other (please provide details)

Do you plan to do any of the following activities?

Scuba dive

Spend time near water

Travel to high altitude

Safari

Jungle travel

Hiking

Spend time in rural communities

Exposure to temperature extremes

Other (please provide details)

Do you have any particular concerns related to your trip?

Getting sick while away

Cost of medications/immunizations

Travellers’ diarrhea

Emergency contacts while overseas

Safety and efficacy of medications

Travel insurance

Malaria

Personal safety overseas

Other (please provide details)

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