Traveling with children, while pregnant or with a chronic health problem? Click here for more information click here.

Health Questionnaire
 Fill out this online form or print and fax it to Dr. Kovner at least seven days before your scheduled appointment.

Completing the questionnaire online does not automatically schedule an appointment.

 

 

Fill out and submit form or download and fax a printable version.

NOTICE: Vaccination and prophylactic medication decrease the likelihood of infection, but do not entirely remove
the risk of illness. Good personal health practices and behavior are essential for healthy travel.

 
PERSONAL INFORMATION
Name Telephone
Birth date Weight if under 12 years
Address City Zip
e-Mail Phone Cell
Company (if business travel)
Company Contact
 
MEDICAL HISTORY
Personal Physician Phone
Address
 
Health Problems: (immune disorders, steroids, diabetes, chemotherapy, joint prosthesis
pace maker, depression fibromyalgia, anxiety, ect)
 
Regular Medications and supplements:
1. 2. 3.
4. 5. 6.
Allergies: (eggs, vaccines, bees, foods, medications)
Pregnant? Y  N
 
Previous Immunizations/year:
Tetanus MMR Polio
 Flu  Pneumonia Typhoid
 Meningitis Hep A Hep B
Japanese Encephalitis TB Skin Test Yellow Fever
 Rabies Varicella  
 
Trekkers: Previous altitude problems? Heart disease? Lung disease? Medical clearance for strenuous activity?
Divers: Recent plastic surgery or body piercing? DCI or hyperbaric treatment? Heart disease? Lung disease? Ear problems?
 
TRAVEL HISTORY
Travel Agent
Travel Medical and Evacuation Insurance
Departure Date
Return Date
List Country and specific locations in sequence:
1.
2.
3.
4.
Itinerary Information:
Previous International Travel:
 
RISK ASSESSMENT
Cruise Y N Hotel Class 0 1 2 3 4 5  Stars
Hostels Y N Camping Y N
Living with Locals Y N Safari Y N
Solo Y N Trekking Y N
Healthcare / volunteer worker Y N Surfing Y N
Diving Y N Rafting Y N
Visiting friends and relatives Y N Zoological studies Y N
Other Risks
 
QUESTIONS AND CONCERNS
 

Vaccines, health precautions, insect protection and malaria prophylaxis are extremely helpful but do not guarantee illness prevention. IF YOU BECOME SERIOUSLY ILL DURING OR UP TO A YEAR AFTER TRAVEL, IT COULD BE MALARIA. SEEK LOCAL CARE OR EVACUATION AT ONCE. Contact your physician and Traveler’s Immunization Center upon your return.

 

Medical Consent for Services: I understand that vaccines can in rare instances cause complications including death. I also understand that the risk of serious harm is less than 1 in 100,000 for persons under 40 years of age but progressively increases to 6 per 100,000 for those over 60 years of age. The risk of serious illness from vaccine preventable infection far exceeds this in areas of high disease prevalence. The vaccines and medications are FDA approved. I agree to accept this risk to decrease my chances of contracting a serious preventable disease. I also give permission for you to provide my physician with a list of vaccines that I have received.


Digital Signature
 I have read and agree to the terms, conditions, and warnings aforementioned.
Date:
Please be sure to submit at least 7 days before your appointment.
Please be sure that requested information is provided.