Patient Name:__________________________________________________________ Date of Birth: _____________ Age: ________ Sex: ______Race: _______ Ethnicity: _______________Mothers Maiden last name: _______________________________________ Address: ___________________________________________City: ___________________________State: __________Zip: ______ Telephone: ___________________ Do you Smoke: Yes No Packs per day _______ How Long? _________________ Medical History:
Have you ever had a serious reaction after receiving a vaccination?
Do you have cancer, leukemia, AIDS, or any other immune system problem?
Do your take cortisone, prednisone, steroids, anticancer drugs or have you had x-ray treatments?
During the past year, have you received a transfusion of blood or blood products or been given
Do you have any existing medical conditions such as diabetes, heart disease or pulmonary disease?
If so, please list: ____________________________________________________________________________________________________ Women only: Are you pregnant, suspect you may be or are trying to become pregnant? Ht: ________ Wt: ______ Allergies (Foods/Drugs)_________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
List all medications you are taking: ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Immunization History: Are you current with immunizations to date?
Have your received any vaccination in the past 4 weeks?
What is the name, address and phone number of your family physician? ____________________________________________________________________________________________ ____________________________________________________________________________________________ Travel Information: Date of Departure: _____________________________Return Date: ____________________________________ Destination: __________________________________ Length of Stay: _________________________________ Destination: __________________________________ Length of Stay: _________________________________ How did you hear about our service: __________________________________________________________________
The above information is true to the best of my knowledge and I authorize IDA to administer the recommended / required vaccinations of my choice. Signature:_____________________________________ Date: _____________________ Vitals: _____ _____B/P _____ _____Pulse _______ __Temp ______ ____Resp Recommended Vaccines: Hepatitis A
Declined vaccines: _____Yes _____ No Comment:_______________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________
Vaccine Lot Expiration Site Route
_____ Aralen 500 mg # _____, 1 tablet po starting one week pre-travel and continuing weekly thru stay and for 4 weeks post travel. _____ Lariam 250mg # ______, 1 tablet po starting one week pre-travel and continuing weekly thru stay and for 4 weeks post travel. ______ Malarone 250mg/100mg # _____, begin 1-2 days pre-travel, daily and continues for 7 days post travel. _____ Malarone 62.5mg/25mg # ______, begin 1-2 days pre-travel, daily and continues for 7 days post travel. _____ Other Rx provided: ______________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ Certification of Immunization provided Yes No
1. Calver P, Braungardt T, Kupchik N, Jensen A, Cutler C. The big chill: improving the odds after cardiac arrest. RN 2005; 68:58-62. Review article written by nurses about the use of mild hypothermia for post cardiac arrest patients. They present a case study on a 53yr old man who they treated with mild hypothermia (33°C) for 24 hours. He woke up 36 hours later with no permanent brain damage an
KMITL SCIENCE AND TECHNOLOGY JOURNAL VOL.13, NO.1, 2013 Antimotility Effect of Machiluss odoratissima & Sonchus wightianus from Nepal Amit Subedi§‡*, Dipak Khakural§, Sadhana Amatya§, Tirtha Maiya Shrestha§§, §Department of Pharmacy, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal. ‡ College of Pharmacy, Yeungnam University, Gyeongsan, Gyeongbuk 712-749, South