Patient name Phone Are you an established patient at Sandy Springs Pediatrics? Itinerary City/Country #1 Mode of Travel Arrival Date Departure Date Duration City/Country #2 Mode of Travel #2 Arrival Date #2 Departure Date #2 Duration #2 City/Country #3 Mode of Travel #3 Arrival Date #3 Departure Date #3 Duration #3 City/Country #4 Mode of Travel #4 Arrival Date #4 Departure Date #4 Duration #4 City/Country #5 Mode of Travel #5 Arrival Date #5 Departure Date #5 Duration #5 City/Country #6 Mode of Travel #6 Arrival Date #6 Departure Date #6 Duration #6 Total Duration 1. What is the purpose of the patient's travel? (i.e. vacation, business, relocation, mission, study, etc.) 2. Describe any planned activities (i.e. hiking, caving, water activities, working with animals, etc.) 3. To what type of area will the patient travel to? (Urban/rural/urban and rural) 4. In what type of accommodations will the patient be staying in? (i.e. hotel, resort, family home, hostel, etc.) Medical History 1. Has the patient ever received the Yellow Fever Vaccine? 2. Has the patient ever had an adverse reaction to any injections? 3. Check box if the patient has allergies to any of the following: 4. Does the patient have a history of any anaphylactic reaction including medications, foods, or insect bites? 5. Has the patient ever taken malaria prophylaxis? 6. Check box if the patient has a history of any of the following: 7. List ALL current medications, including prescription, non-prescription, supplements, oral contraceptive pills: 8. Has the patient had any blood product transfusions or injections in the last 12 months (i.e. blood transfusion, IVIG, VZIG, etc.)? 9. Is the patient currently or is there a chance that the patient could become pregnant during travel?
Please note that Travel Consults are not covered by insurance carrier. You will be require to self-pay for the visit and any vaccines if needed.