Kroger Pharmacy Travel History Form Page 2
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4TRAVEL HISTORY FORM
Upon completion of this form please call your Kroger Pharmacy to set up an appointment
Will you be?
YES
NO
Visiting ONLY major cities? If no, explain:
Staying ONLY in hotels? If no, explain:
Visiting friends and family?
Ascending to high altitudes ( >7,000 feet or 2,300 meters) in the mountains?
Working in the medical or dental field with exposure to blood or other bodily fluids?
Working with or exposure to animals?
Potentially having new sexual partners?
ALLERGIES
No Known Drug Allergies
No Known Food Allergies
Have you had any allergic reactions to any of the following? (Please check all that apply)
Eggs (e.g.: birthday cake)
Quinines (Chloroquine [Aralen], Mefloquine [Lariam]
Sulfa Drugs (e.g.: Bactrim, Septra)
Hydroxycholoroquine [Plaquenil], Primaquine)
Antibiotics (e.g.: Neomycin, Streptomycin)
Pyrimethamine
Thimerosal (preservative)
Tetracyclines (Doxycycline, Minocin, Minocyclin)
Latex
Chrysanthemums
Other:
Please list any adverse reactions due to previous vaccinations and/or antimalarial medications:
__________________________________________________________________________________________________
IMMUNIZATIONS
Yes
No
1. Were you born in the United States?
(if no, country of birth: ___________________)
2. Have you completed the following immunizations? (please bring your vaccination record to your appointment)
Yes
Date(s):
______
______
No
Not Sure
Hepatitis A
Yes
Date(s):
No
Not Sure
Hepatitis B
Yes
Date(s):
No
Not Sure
Meningococcal Meningitis
Yes
Date(s):
No
Not Sure
Japanese Encephalitis
Yes
Date(s):
No
Not Sure
MMR (measles, mumps, rubella)
Yes
Date(s):
No
Not Sure
Polio Series
Yes
Date(s):
No
Not Sure
Tetanus (Td, Tdap)
Yes
Date(s):
No
Not Sure
Typhoid
Yes
Date(s):
No
Not Sure
Yellow Fever
Yes
Date(s):
No
Not Sure
Flu
Yes
Date(s):
No
Not Sure
Other:
Have you had a Tuberculin Skin Test (TST) done recently? If so, when: ________________________
3.
MEDICAL HISTORY
1. Are you using steroids, receiving radiation therapy or other immunosuppressive chemotherapy?
Yes
No
2. List your regularly used non-prescription medications (over-the-counter, herbal, homeopathic, vitamins, etc)
Regularly Used Non-Prescription Medications
Condition or Reason for Use
(include name, dose, and directions)
Page 2 of 4
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