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Microsoft word - ida health and travel.doc

IDA Health and Travel
Riverdale, GA 30274

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

Comments: __________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
Nurse Signature: ___________________________________________ Date: _________________________

Source: http://www.idapc.com/client_files/file/IDA-Health-and-Travel.pdf

Microsoft word - as cooling references summaries 8-3-06.rtf

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

Paper title (use style: paper title)

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

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