Kroger Pharmacy Travel History Form Page 3
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4TRAVEL HISTORY FORM
Upon completion of this form please call your Kroger Pharmacy to set up an appointment
3. List your current prescription medications and medical conditions treated: (include birth control pills)
Current Prescription Medications
Condition or Reason for Use
(include name, dose and directions)
4. Are you planning any surgeries, dental procedures, tattooing, body piercing or any other procedures involving
Yes
No
blood or skin puncture?
If YES, please elaborate: _______________________________________________________________________
___________________________________________________________________________________________
5. Have you been told you have any of the following medical conditions (check all that apply)?
Anemia
G6PD Deficiency
Liver Disease/Hepatitis
Asthma
Gout
Lung Disease
Blood Clotting Problems
Hearing Problems
Prostate Problems
Cancer
Heart Disease
Psoriasis/Other Skin Problems
Depression
High Blood Pressure
Psychiatric Problems
Diabetes
Sickle Cell Disease
Stomach Ulcer
Ear Infections (Chronic)
Hormone Problems
Stroke
Epilepsy/Seizures
Immune System Deficiency
Thyroid Problems
Eye Problems
Kidney Disease
Other/Comments:__________________________
6. For Women Only: 1) First day of last normal menstrual period:
Yes
No
3) Are you breast-feeding?
Yes
No
2) Are you or could you be pregnant?
7. Primary Care Physician/Provider Name:___________________________________________________________
QUESTIONS/CONCERNS
Please list additional questions or concerns that you might have regarding your travel? (i.e: international voltage
requirements, currency exchange, dealing with seasickness, etc.)
__________________________________________________________________________________________________
Do we have your permission to process vaccines and other preventative medication prescriptions recommended for
Yes
No
your trip under your prescription drug plan, prior to consultation?
_____________________________
______________________________
___ /___ /____
Print Name
Patient’s Signature
Date
Page 3 of 4
“The information contained in this communication may be privileged and confidential and may be protected from disclosure. If the reader of this message is not the intended recipient, or an employee or
agent responsible for delivering this message to the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have
received this communication in error, please notify us immediately.”
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