Travel Clinic Screen Form Page 2
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2Tulalip Clinical Pharmacy 8825 34th Avenue NE, Suite A, Tulalip, WA 98271 360-716-2660
Medical History: (failure to disclose history may result in improper treatment)
___ Yes ___ No
1.
Any illness or medical problems in the past five years needing physician follow-up?
___ Yes ___ No
2.
Have you ever been treated for severe depression or psychiatric disorder?
___ Yes ___ No
3.
Do you have impaired liver function?
___ Yes ___ No
4.
Do you have severe kidney impairment?
___ Yes ___ No
5.
Do you have underlying cardiac conduction disturbances or irregular heartbeat?
___ Yes ___ No
6. Have you ever been tested for G6PD deficiency?
___ Yes ___ No
7.
Do you take quinine, quinidine, beta blockers, digoxin or any drug that alters cardiac conduction?
___ Yes ___ No
8.
Do you have a history of seizures or epilepsy?
___ Yes ___ No
9.
Do you take medications to control seizures?
___ Yes ___ No
10. Do you have a history of psoriasis?
___ Yes ___No
11. Do you have current or past disease of the retina (eye) or changes to your field of vision?
___ Yes ___ No
12. Do you take the medication cimetidine (Tagamet)?
___ Yes ___ No
13. Do you have a history of a reaction to any antibiotic medications containing sulfa such as (Bactrim, Septra or
Cotrim)?
___ Yes ___ No
14. Do you take the medication Lipitor or any other statin drug for high cholesterol?
___ Yes ___ No
15. Do you have Myasthenia Gravis, take Accutane (for acne) or have an allergy to tetracycline drugs?
___ Yes ___ No
16. Do you take tetracycline (for acne), metoclopramide (for nausea), rifampin (TB med), rifabutin (for bacterial
infections), indinavir (HIV medication) or theophylline (for lung disease)?
___ Yes ___ No
17. Do you take Coumadin (warfarin) as a blood thinner?
___ Yes ___ No
18. Do you take hydrochlorothiazide (HCTZ), Lasix or other diuretic medication?
___ Yes ___ No
19. Do you take oral contraceptives?
___Yes ___ No
20. Are you trying to get pregnant during this trip or in the 3 months that will follow completion of antimalarial
medication?
___ Yes ___ No
21. Are you pregnant now?
If so, how far along are you? __________
___ Yes ___ No
22. Are you breastfeeding?
Authorization to Release Protected Health Information
Primary Care Provider __________________________________________
Phone _____________________________________
I request & authorize Tulalip Clinical Pharmacy to exchange with or release health care information of the person named above with
my primary care provider for the sake of care coordination.
I understand that signing this form is voluntary. I do not need to sign this form in order to receive healthcare treatment.
th
I have the right to cancel this authorization at any time by writing to the Tulalip Clinical Pharmacy Director at 8825 34
Avenue NE,
Tulalip, WA 98271.
Unless crossed out, I authorize release of all health information relating to diagnosis, testing or treatment for HIV/AIDS, sexually
transmitted disease, psychiatric disorders/mental health, or drug/alcohol abuse.
This authorization expires on (date or event) _______________, or 12 months from the date signed if not specified. A copy of this
document may be considered the same as the original.
_________________________________________________
Client Full Name (print)
_________________________________________________
___________________________
Client signature
Date
_________________________________________________
___________________________
Immunizer signature
Date
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