London Travel Clinic Sample Patient Information Form

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Last Name: _____________________________________ First Name: _____________
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Sex: M
F
Pregnant? Y
N
Appointment Date YY/MM/DD: ___/___/___ Depart Date YY/MM/DD:___/___/___
Birth Date YY/MM/DD: ___/___/___ Country of Birth: ________________________
Address: ________________________________City/Town: _____________________
Postal Code: _________ Phone: ( ) ___________
Duration of Travel (days):_______________
Planned Country(ies) of Destination:________________________________________
Location(s) in Country(ies) of Destination: ___________________________________
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Reason for Travel: Business
Tourism
Backpacking
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Visit Relatives Friends
Live and Work
Other: ________________________
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Previous Canadian Immunizations: Up to date
None in over 10 years
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Don’t know
(Information often available at Public Health Unit)
Year of Previous Travel Immunizations: Hepatitis A ________ Typhoid Vi________
Typhoid Oral
________ Yellow Fever _________ Japanese Enceph ________
(Vivotif)
Other:______________
Other:______________
Underlying Medical Conditions: ___________________________________________
Current Medications: ____________________________________________________
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Drug Allergy: Y
N
Drug Names: ______________________________________
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Egg Allergy: Y
N
Other Allergies:_____________________________________
Thank You! Please bring this optional form with you to your appointment.
All information will be kept confidential in your chart.

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