Ranchlands Pre-Travel Questionnaire

1
Pre-Travel QuestionnaireNote : Please bring any vaccination records (childhood/travel), travel itinerary and confirmation of this form submission when you arrive at the clinic. Please fill this form for each member of the family separately.
2
Full Name* This field is required.
First Name
Last Name
3
Your Contact InformationPlease enter at-least one form of contact information or both.
Please enter your phone number
Please enter your email
4
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
What is your Gender?
Male
Female
6
What is your date of birth?Please type or choose your date of birth
Date
Year
Month
Day
7
What is your weight?
8
Alberta Healthcare NumberEnter your Alberta healthcare number here
9
Family Doctor's NameType your family doctor's name
First Name
Last Name
10
Your Family Doctor's AddressType your family clinic or doctor address if known
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
11
Family Doctor's Phone NumberIf Known
Area Code
Phone Number
12
Family Doctor's Fax NumberIf Known
Area Code
Phone Number
13
Have you been immunized as a child?If yes please provide details on the next page
YESNO
14
Please provide details of childhood immunizationPlease provide if any known details or provide immunization record copy if available.
15
When are you planning to travel?Please provide the approximate date of travel
Date
Year
Month
Day
16
Where are you planning to travel?Please list all the countries and cities you are planning to travel. To enter multiple cities of a same country please click "SAVE AND ADD ROW" and leave country column blank after the first entry until you finish entering all the cities of that same country.Once you added all the cities of the same country please add other countries and cities.
17
What is the duration of your total trip?Please mention the duration of stay. Eg. 1 Month, 2 Weeks
18
What is your purpose of travel?Please define your purpose of travel
Business or work
Vacation
Volunteer/Mission
Backpacking
Visting Family/Friends
Other
19
What are the activities planned during travel?Select all that applies
Rural/remote
Urban/city
Diving
High Altitude
Surfing
Camping
Climbing
Swimming
Tour
Snowboarding
Other
20
Please answer the following health history questions to the best of your ability (Check All that apply)If you are unsure or not aware please move on to the next question.
21
Have you had any side effects/reactions from previous medications?If Yes, please describe them on the next page.
YESNO
22
Describe your experience
23
Your Immune System:
Steroids by mouth within last 3 Months
Immune suppressive medications or treatments within last 3 months. ( e.g: radiation, cancer chemotherapy drugs, methotrexate, azathioprine, adalimumab, anakinra, etanercept, infliximab, leflunomide, rituximab)
Spleen removed
Thymus disease or thymectomy
HIV/AIDS
Organ, bone marrow, stem cell transplant
Other
24
Cardiovascular
Arrhythmia (rhythm disturbance considered significantly abnormal including atrial fibrillation, heart block)
Implanted pacemaker or automatic defibrillator
Heart attack
High cholestrol
High blood pressure
Stroke
Other
25
GI
Chrohn's disease or ulcerative colitis
IBS
GERD
Chronic hepatitis
Cirrhosis or liver failure
Other
26
Neurologic/psychiatric
Seizures or epilepsy
Anxiety/depression
History of Guillain-Barre
Chronic hepatitis
Other
27
Cancers or blood disorder
Coagulation disorder
History of cancer or blood disorder
Other
28
Kidneys
Dialysis
Kindney insufficiency
Other
29
Lungs
Asthma
Emphysema/COPD
Other
30
Endocrine
Diabetes
Thyroid disease
Other
31
Musculoskeletal
RA
Psoriatic arthritis
Other
32
Skin
Psoriasis
Other
33
OB/GYN
Pregnant
Breastfeeding
Possible pregnancy in next 3 months
Other
34
Please check if you have any allergies to the following:* This field is required.
Antibiotics (e.g: penicillin, sulfa)
Other medications
Egg
Latex
Gelatin
Yeast
Bees/wasps
Seasonal
None
Other
35
Are you currently taking any medication?* This field is required.
Yes
No
36
Current MedicationsList all current prescription medications
Medication 1
Reason for use 1
Medication 2
Reason for use 2
Medication 3
Reason for use 3
Other medications
37
Non-Prescription ProductsList all current over the counter medications, herbal, homeopathic, vitamins and supplements
Product 1
Reason for use 1
Product 2
Reason for use 2
Product 3
Reason for use 3
Other
38
Your Vaccination HistoryPlease bring all vaccination records to your appointment. Please answer the following vaccination history questions.
39
Have you received Hepatitis A immunizations in the past?If Yes, please provide details such as approximately when and how many doses in the next page.
YESNO
40
Hep A DetailsPlease provide any details as far as you can remember
Eg : When, How many doses?
41
Have you received Hepatitis B immunizations in the past?If Yes, please provide details such as approximately when and how many doses in the next page.
YESNO
42
Hep B DetailsPlease provide any details as far as you can remember
Eg : When, How many doses?
43
Have you received Hepatitis A&B immunizations in the past?If Yes, please provide details such as approximately when and how many doses in the next page.
YESNO
44
Hep A & B Combined DetailsPlease provide any details as far as you can remember
Eg : When, How many doses?
45
Have you received any Meningococcal vaccines in the past?If Yes, please provide details such as approximately when and how many doses in the next page.
YESNO
46
Details of your Past Meningococcal VaccinesPlease provide any details as far as you can remember
Eg : When, How many doses?
47
Have you received any immunization for Measles/Mumps/Rubella in the past?If Yes, please provide details such as approximately when and how many doses in the next page.
YESNO
48
Details of Your Past Immunization for Measles/Mumps/RubellaPlease provide any details as far as you can remember
Eg : When, How many doses?
49
Have you received any vaccination for Polio in the past?If Yes, please provide details such as approximately when and how many doses etc in the next page.
YESNO
50
Details of Your Past Polio VaccinationsPlease provide any details as much as you can remember
Eg : When, How many doses?
51
Have you received any vaccination for Tetanus in the past?If Yes, please provide details such as approximately when and how many doses etc in the next page.
YESNO
52
Details of Your Past Tetanus VaccinationsPlease provide any details as much as you can remember
Eg : When, How many doses?
53
Have you received any vaccination for Typhoid in the past?If Yes, please provide details such as approximately when and how many doses etc in the next page.
YESNO
54
Details of Your Past Typhoid VaccinationsPlease provide any details as much as you can remember
Eg : When, How many doses?
55
Have you received any vaccination for Yellow fever in the past?If Yes, please provide details such as approximately when and how many doses in the next page.
YESNO
56
Details of Your Past Yellow Fever VaccinationsPlease provide any details as far as you can remember
Eg : When, How many doses?
57
Have you received any vaccination for Japanese Encephalitis in the past?If Yes, please provide details such as approximately when and how many doses in the next page.
YESNO
58
Details of Your Past Japanese Encephalitis VaccinationsPlease provide any details as far as you can remember
Eg : When, How many doses?
59
Have you received any immunization for influenza or other conditions not listed above ?If Yes, please provide details such as approximately when and how many doses in the next page.
YESNO
60
Provide details of your Influenza or any other immunizationPlease provide any details as far as you can remember
Eg : When, How many doses?
61
Have you ever had an adverse reaction to an immunization?
YESNO
62
Explain your adverse reaction to immunization
63
Do you use or do you have history of using tobacco?
No
Please Select
Yes
No
64
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
65
Questions or concernsList any additional questions or concerns you might have.
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Patient Consent and DeclarationSigned at the clinic
By signing below I, above named consent to receiving the vaccines as documented by Ranchlands Pharmacy's certified Pharmacists and approved Travel Consultant. I am also aware that it is recommended that patients wait for a minimum of 15 minutes prior to departing the pharmacy after vaccination. 

Signature :Signature of patient or Guardian
67
Travel consultant or pharmacist commentsThis portion is for office use only. Do not fill this section. Your pharmacist or travel consultant will fill this at the clinic.
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68
References CheckedThis portion is for Pharmacist and Travel Consultant Use Only
69
Pharmacist Signature
Should be Empty: