Catonsville Travel Vaccines Online Questionnaire
Date
Last Name
First Name
Address
State
City
Zip
Age
 Sex
 E-Mail
Date of Birth
Home phone
 Cellphone
Referred by
Doctor
CDC Website
Search Engine
Friend/  Relative/ Coworker
Another Website
Your Website
I am a previous customer
Company
Occupation
Primary Care Physician
Phone
Address
Type of Service(s)  Requested
Medical History Required for all services
OFFICE SERVICES - payment is expected at time of office visit
Office Consultation $75.    Appointment must be made
Second person Consultation $45
Vaccines for Travel.    Administration fees  plus cost of vaccines.  Client knows which vaccines he
wants
Vaccines for Non-Travel Only- Administration fees plus cost of vaccines.  May Skip the Travel Section of the
Questionnaire
Prescriptions for Travel  $25.  Such as malaria, attitude sickness, traveler's diarrhea.   Please list in
"Vaccines and Prescriptions" section below
PPD (Tuberculosis Screening)  $25
Travel Information -Please skip if not Traveling
Medical History is also Required for all travelers.
Please list the countries you
are traveling to and the length
of stay in each country below
Departure Date
Return Date
Reason for Travel
Tourist
Visiting Friends and Relatives
Business
 Mission
Other
Accommodations= Check all that apply
Hotel
 Youth Hostel
Camping
Family/Home
Cruise
Check all that apply.  I plan to:
Visit Rural Areas
Visit only tourist areas
Scuba dive
Go bicycling
Swim in Ocean
Travel to or climb to high altitudes
Swim in fresh water lake or stream
Drive car or motor scooter
Go hiking or backpacking
Vaccines and Prescriptions
Medical History Required for these services
Requesting prescription for Malaria:
YES
Prescriptions for Malaria and other
Medications:  If you already know what
you want please list here
Vaccines- If you already know what you
want please list here
Medical History
Medical History Required for all services
None
 Current or Previous Medical Conditions
Current Medications
None
Please Check Yes or No. Use the additional comments area to provide additional information
  YES
 NO
Any adverse reactions to a previous immunization?
Are you pregnant or suspect that you might be pregnant?
Any known allergies to medications, etc?
Do you have a cold, fever, wheezing, or any other acute illness?
Any sensitivity/allergy to latex, eggs, insect/bee stings, quinine, or thimersal (cleaning products or
contact lens solution)?
Do you have a chronic mental or physical condition?
Do you have a history of Gillian-barre Syndrome, seizures, high blood pressure, eczema, motion
sickness, or active neurological disorder?
Do you, or any person you are in close contact with, have immune system problems including HIV/Aids,
cancer, or leukemia?
Do you have a history of depression or anxiety?
Additional Comments
PAYMENT for OFFICE SERVICES
I understand that for office services payment is expected at time of service, in
the office,  with cash, debit,  or credit card.
CONFIRMATION
The above information is true and accurate to the best of my knowledge.
Relationship
to Patient
Print Name
Cancel
NOTE: AFTER SUBMITTING THE FORM, CALL OUR OFFICE TO
SCHEDULE AN APPOINTMENT.