Atlanta Travel Medicine

Patient's Information (Required)

First Name

Last Name

Age

Date of Birth

/ /

Email

Sex

Male Female

Address

City

State

Zip Code

Home Phone

Work Phone

Cell Phone

Emergency Contact

Relationship

Phone

Travel Plans (Required)

Type of Travel: Business Tourist Student Mission

Will you have access to medical care if necessary? Yes No

Destination(s) of Travel:
(Include dates of arrival and departure for each country and rural travel expected for each)

Medical History (Optional)

Current/Ongoing Medical Conditions:

Past/Resolved Medical Conditions and Surgeries:

Do you have any conditions which could lower your immune system? Yes No

Are you pregnant? Yes No Are you breastfeeding? Yes No

Current Medications with Dosages:

Allergies: (Click any of the following to which you are allergic)

Eggs Thimerisol Sulfa Neomycin Streptomycin Bee Stings

Other

Vaccine History: (Please note any of the vaccinations or diseases you have had below, with dates if possible)

Have you received at least 3 doses of tetanus/ diptheria (Td) vaccine in the past?
(Includes DPT doses as a child)

Yes No

When was your last tetanus/diptheria shot given?

Have you received at least 3 doses of Polio vaccine in the past? (Including childhood doses)

Yes No

Date of last dose:

Other vaccines with dates not listed above (pneumococcus, influenza, rabies, small pox, etc):

How did you find out about us? Physician Friend/Family Google Yahoo Kudzu Yellow Pages

Other (please list):

Please bring any immunization records you may have to your visit.

Please submit this form before your visit.

Atlanta Travel Medicine, L.L.C, 5673 Peachtree Dunwoody Road, Suite 330, Atlanta, Georgia 30342, Phone: 404-941-1317