Cahoon's Pharmasave
WE ALWAYS HAVE TIME FOR YOU
95 Deep River Road
Deep River, Ontario
P:
613.584.1116
|
F:
613.584.1118
Hours
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About Us
About Us
Our Team
Services
Services
Home Health Care
Rx Refill
Community
Events
Flyer
Contact
About Us
About Us
Our Team
Services
Services
Home Health Care
Rx Refill
Community
Events
Flyer
Contact
Travel Health
1. Personal Details
Please complete the form below:
Name
*
Date Of Birth
*
Health Card Number
*
Gender
*
Male
Female
Primary Care Provider
*
Weight ( please add kg or lbs beside your weight )
*
Email Address
*
Telephone
*
Full Address
*
2. Personal Medical History
Are you currently pregnant or breastfeeding?
Yes
No
Have you received any vaccinations within the past 28 days?
Yes
No
Have you had a fever within the last 7 days?
Yes
No
Do you have a personal history of HIV/AIDS, Hepatitis B, Hepatitis C, or other blood-borne illness?
Yes
No
Have you recently undergone radiation or chemotherapy or used immunosuppressive drug therapies including Humira, Remicade, Enbrel or high dose corticosteroids?
Yes
No
Do you currently have any medical conditions leading to suppressed immune function, ie. HIV infection, leukemia, lymphoma, thymic disease, generalized malignancy?
Yes
No
Are you aware of any existing or past issues with your liver or kidneys?
Yes
No
Do you have a personal history of blood clots?
Yes
No
Do you have any known allergies?
Yes
No
Notes regarding any positive responses to above questions:
3. Medication Record
The pharmacist will perform a MedsCheck with all travellers prior to preparing the final travel plan. Please bring all prescription and non-prescription items with you to your consultation
4. Vaccination History
(Bring record with you to appointment)
Influenza (flu shot)
Yes
No
Unsure
Pneumococcal
Yes
No
Unsure
Tetanus
Yes
No
Unsure
HPV - human papillomavirus
Yes
No
Unsure
MMR - measles, mumps, rubella
Yes
No
Unsure
Polio
Yes
No
Unsure
Varicella
Yes
No
Unsure
Shingles
Yes
No
Unsure
Hepatitis A
Yes
No
Unsure
Hepatitis B
Yes
No
Unsure
Yellow Fever
Yes
No
Unsure
Japanese encephalitis
Yes
No
Unsure
Tick borne encephalitis
Yes
No
Unsure
Typhoid
Yes
No
Unsure
Travelers diarrhea (Dukoral)
Yes
No
Unsure
Meningitis
Yes
No
Unsure
5. Travel Itinerary
Please complete in chronological order of travel as it may influence which vaccines are required. List all towns, villages, cities, etc. to be visited as vaccination requirements may differ within the same country.
1. Location
Accommodations
Date of Arrival
Date of Departure
2. Location
Accommodations
Date of Arrival
Date of Departure
3. Location
Accommodations
Date of Arrival
Date of Departure
4. Location
Accommodations
Date of Arrival
Date of Departure
5. Location
Accommodations
Date of Arrival
Date of Departure
6. Location
Accommodations
Date of Arrival
Date of Departure
7. Location
Accommodations
Date of Arrival
Date of Departure
8. Location
Accommodations
Date of Arrival
Date of Departure
9. Location
Accommodations
Date of Arrival
Date of Departure
6. Trip Details
What is the reason for travel?
Pleasure/Relaxation
Business
Healthcare (providing)
Healthcare (receiving)
Sport/Recreation
Aid/Relief
Adventure/Exploration
Other: (please provide details)
What is your level of travel experience?
Within Canada, never out of country
Within North America, never overseas
Travelled overseas, never to destination
Travelled to destination
Who are you travelling with?
Solo
Family
Friends
Young children
Seniors
Group (please specify)
Group (please include details )
Other (please provide details)
Who organized the trip?
Self-organized
Friend
Employer
Travel Agent
Charitable organization
Church
Other (please provide details)
What is the nature of the accommodations?
All-inclusive resort
Personal residence
Premium hotel
Cruise ship
Budget hotel
Car camping
Hostel
Backpacking/trekking
Other (please provide details)
Do you plan to do any of the following activities?
Scuba dive
Spend time near water
Travel to high altitude
Safari
Jungle travel
Hiking
Spend time in rural communities
Exposure to temperature extremes
Other (please provide details)
Do you have any particular concerns related to your trip?
Getting sick while away
Cost of medications/immunizations
Travel to high altitude
Travellers’ diarrhea
Emergency contacts while overseas
Safety and efficacy of medications
Travel insurance
Malaria
Personal safety overseas
Other (please provide details)
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