Patient Sick Release Form - DOC by pvi74282

VIEWS: 10 PAGES: 5

More Info
									                                                                                    IMU FOUNDATION
                                                                                  The IMUnization Clinic




Last Name _____________________________ First Name __________________________                     Middle Initial ______

Street Address _________________________________________ City _______________, St. ______ Zip _________

Telephone ____________________                                    Date of Birth _______________     Age ___________




□Asian     □           □               □                □                     □
□          □           □               □                 □                     □
                                                  / /   /   /     /   /   /   /
                                         /   /    / /   /   /     /   /   /   /
                                         /   /    / /   /   /     /   /   /   /
                                         /   /    / /   /   /     /   /   /   /
                                         /   /    / /   /   /     /   /   /   /
                                         /   /    / /   /   /     /   /   /   /     SP
                                         /   /    / /   /   /     /   /   /   /     SP /
                                         /   /    / /   /   /     /   /   /   /     SP
                                         /   /    / /   /   /     /   /   /   /     SP
                                         /   /    / /   /   /     /   /   /   /     SP
                                         /   /    / /   /   /     /   /   /   /
                                         /   /    / /   /   /     /   /   /   /
                                         /   /    / /   /   /     /   /   /   /
                                         /   /    / /   /   /     /   /   /   /
                                         /   /    / /   /   /     /   /   /   /
                                         /   /    / /   /   /     /   /   /   /
                                         /   /    / /   /   /     /   /   /   /
                                         /   /    / /   /   /     /   /   /   /
                                         /   /    / /   /   /     /   /   /   /
                                         /   /    / /   /   /     /   /   /   /
                                         /   /    / /   /   /     /   /   /   /
                                         /   /    / /   /   /     /   /   /   /
                                         /   /    / /   /   /     /   /   /   /
                                         /   /    / /   /   /     /   /   /   /
                                                 / /            / /
                                         / /      / /   / /       /   /   / /



               Clinic/Site Location: 414B North Sam Houston Parkway East, Houston, TX 77060-3508
                                                                 IMU FOUNDATION
                                                               The IMUnization Clinic
                  Given    / /   Read   / /     mm
                  Given    / /   Read   / /     mm




Clinic/Site Location: 414B North Sam Houston Parkway East, Houston, TX 77060-3508
                                                                                                 IMU FOUNDATION
                                                                                               The IMUnization Clinic




             SCREENING QUESTIONAIRE FOR INTERNATIONAL TRAVEL
Medical History of: (your name)
Occupation:                                                    Email Address:

Primary Physician:                                             Telephone:
Office Address:
City:                                        State:                             Zip Code:

Should we send a copy of your Immunization record to your Primary Physician?
Yes              No

Destination of Travel:

1. Where are you going? [Please list countries and areas within countries, rural vs. urban]:


2. Date of Departure:                                 Date of Return:

3. Purpose of Travel: Business         Pleasure               Mission Study     Service

4. Name of Church or Business Affiliation for the trip:
   Address:

Health History:
Allergies:
Weight:                               Height:

Medications: [Please list all medications currently being taken]

       Prescription:
  Non Prescription:

Medical Conditions:


Previous Surgery(s):


Check if you have present or past history of the following:    Nightmares     Psoriasis   Psychiatric Disorders/Depression
 Seizures/Epilepsy Stomach/Colon Problems

I verify that the above information is complete and correct to the best of my knowledge:

Signature:                                                         Date:
Reviewed by:                                                       Date:



                        Clinic/Site Location: 414B North Sam Houston Parkway East, Houston, TX 77060-3508
                                                                                                            IMU FOUNDATION
                                                                                                          The IMUnization Clinic




       The following questions will help us determine which vaccines you may be given today. If you                          DON’T
                                                                                                                  YES   NO   KNOW
       answer “yes” to any question, it does not necessarily mean you should not be vaccinated. It just means
       additional questions may be asked. If a question is not clear, please ask and we will explain it to you.
1.
2.     Are you [the patient] sick today?

3.
4.     Do you [the patient] have any allergies to medications, food, or any vaccine? If yes, please list:
       _______________________________________________________
5.
6.     Have you [the patient] ever had a serious reaction after receiving a vaccination?
       If yes, please explain: _________________________________________________
7.
8.     Do you [the patient] have cancer, leukemia, AIDS, or any other immune system problem? If yes,
       please list: ____________________________________________

       Do you [the patient] take cortisone, prednisone, other steroids, or anticancer drugs, or have you
       had x-ray treatments?

       Do you [the patient] have a seizure, brain, or nerve problem? If yes, please explain:
       ____________________________________________________________

       During the past year, have you [the patient] received a transfusion of blood or blood products,
       or been given a medicine called immune [gamma] globulin?

       Have you [the patient] received any vaccinations in the past 4 weeks?


       For Women: Are you pregnant or is there a chance you could become pregnant during the next
       month?

       For Women: Have you had a mastectomy or any lymph node removal? If yes, please explain
       [indicate left or right side]: ________________________________

       Did you bring your immunization shot record/card with you today?


                            SCREENING QUESTIONNAIRE FOR CHILD/ADOLESCENT/ADULT IMMUNIZATION
                                                     ADMINISTRATION

     PATIENT NAME: ______________________________________                        DATE OF BIRTH: ______________

      How did you hear about us?: _______________________________________________________
      Would you like an email reminder for follow-up appointment(s)? _______________
      If Yes, please list email address: ____________________________________________________

      FORM COMPLETED BY: ________________________________                       DATE: ____________________


                               Clinic/Site Location: 414B North Sam Houston Parkway East, Houston, TX 77060-3508
                                                                 IMU FOUNDATION
                                                               The IMUnization Clinic
 The IMUnization Clinic * 414B N. Sam Houston Pkwy East * Houston, TX 77060-3508




Clinic/Site Location: 414B North Sam Houston Parkway East, Houston, TX 77060-3508

								
To top