Hammond Health Center – Ithaca College Phone - (607) 274-3177 Fax (607) 274-1844 Name: _____________________________________________ ID#_____________________ DOB: __________________
Purpose of Trip: [] School Related Study/Work What school?___________________________________________
[] Other: _______________________________________________ What will you be doing on this trip?_________________________________________________________________
Does your program require the completion of a medical form by a practitioner? [] Yes [] No
Departure Date from United States: _______________________ Return Date to United States:___________________
Countries AND cities to be visited in order of visits
A. Have you traveled outside the United States before? If yes, where and when? _______________________________________________________________________ B. Will you be: [] Yes [] No Visiting ONLY urban areas? If no, explain ___________________________________
____________________________________________________________________ Staying ONLY in Hotels? If no explain ______________________________________
____________________________________________________________________ Ascending to high altitudes (>7,000 ft. or 2,300 meters) in the mountains? Working in the medical or dental field with exposure to blood or other body fluids? Potentially having sexual contact with new partners? ALLERGIES
1. [] No known drug allergies
2. Have you had an allergic reaction to any of the following? (please check all that apply) [] Eggs [] Quinines (Chloroquine [Aralen}, Mefloquine [Lariam] [] Sulfa Drugs (e.g. Bactrim, Septra, Gantrisin) Hydroxychlorogquine [Plaquenil], Primaquine) [] Antibiotics (e.g. Neomycin, Streptomycin) [] Thimerosal (preservative in contact lens solution) [] Tetracyclines (Doxycycline, Minocin, Minocyclin, [] Chrysanthemums [] Other:_______________________________________ Have you had any other vaccines (other than routine childhood vaccines)? -if yes, list what and when: (please bring record with you to appt): Have you ever taken medication for malaria prevention or treatment? Have you ever had any adverse effects from vaccines or malaria medication? -if yes, what vaccines or medication and describe adverse effect?____________ _________________________________________________________________ Have you ever had a positive PPD test for tuberculosis? Do you have a history of emotional illness (such as depression, anxiety, or psychosis)? Do you have a history of neurologic illness (such as multiple sclerosis)? Do you take any medications for your stomach (such as antacids, ranitidine, or Prilosec)? Do you take oral steroids (such as prednisone)? Are you currently being treated for cancer? Do you have a deficiency of your immune system? Do you have a history of jaundice or hepatitis? Do you have a history of retinal or visual problems? Are there any immune-suppressed persons living in your household? Are you pregnant, or do you plan to try to get pregnant in the next 3-6 months? Do you have any existing medical conditions (such as diabetes, heart disease or asthma)? -if yes, describe:______________________________________________________________ Have you had any serious illnesses or hospitalizations in the last three years? -if yes, please describe:________________________________________________________ Do you have any disabilities that will require special arrangements while traveling? -if yes, please describe:________________________________________________________ Do you take any medications regularly (including birth control pills)? -if yes, please list:____________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Do you use any herbal medicines or over the counter medicines regularly? -if yes, please describe:________________________________________________________ Do you have any special questions or concerns to address during your visit? -if yes, please describe:________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________


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