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HTMOA REGISTRATION FORM

Highland Travel Medicine

PATIENT INFORMATION
Travel Destination : *
Today's Date : * MM / DD / YYYY
PCP :
Name : * Title First Last Suffix
Is this your legal name? *
If not, what is your legal name? First Last
(Former Name) : First Last
Marital Status : *
Sex : *
Birth Date * MM / DD / YYYY
Age *
Street Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Employer : *
Occupation : *
Employer Phone Number : ### - ### - ####
Who should we thank for referring you?
Their Name :
Other family members seen here :
IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address) * First Last
Relationship to patient : *
Home Phone Number : * ### - ### - ####
Work Phone Number : * ### - ### - ####
MEDICAL HISTORY
Reason for visit *

What brings you here today? Major concerns? Key questions/agenda/goals for appointment?
Women Only
Do you have regular periods?
Are you taking birth control pills?
Have you ever been pregnant?
Number of pregnancies :
General
Are you currently under medical treatment? *
If yes, please describe :
Have you ever had any serious illness or operation? *
If yes, please describe :
Are you currently taking any medication? *
If yes, please describe :
Do you have allergies to any medications or antibiotics? *
If yes, please describe :
Have you ever had Thymus surgery or radiation treatment to your chest? *
Are you allergic to eggs, egg products, or chicken? *
Do you smoke? *
Do Not Fill This Out