Last name

First name

Address

City

Postal Code

Home phone     

Work phone

Emergency

Date of Birth

Manitoba Health # (6digit)

9 digit phin#

Medical Problems

Allergies

Prior reactions to Immunizations

Egg Allergies ?

Current Medications

Additional Notes:

Purpose of trip

Itinerary- countries visited

Arrival and departure at each country

Malaria Prevention

Adult Dosing

Amount prescribed

Chloroquine

500mg per week, start one week before, continue weekly and for 4 weeks after trip

N= 1+wks+4

Mefloquine

250mg per week, start one week before, continue weekly and for 4 weeks after trip

N= 1+wks+4

N=1+wks+4

Doxycycline

100mg per day starting 2 days before, while on trip and for 4 wks after

N=2+days+28

Malarone

One pill 2 days before trip, daily on trip and for additional 7 days

N=2+days+7

Altitude Medication:

Diamox 250mg one half tab

1 day before and 3 days after ascension

Travelers Diarrhea Medication :

Ciprofloxacin 500 twice daily for up to 3 days

Zithromax 500mg daily for 3 days in Pregnant women

Or age appropriate loading dose for children

Vaccine

Description

Price or tariff and

IDC9

Date

Date

Date

Travel Visit

Fee for time in clinic Initial assessment

40$ 1 st visit

Follow-up boosters

20$ repeat visit

Tetanus

diptheria(Td)

After childhood primary vaccine series every 10yrs

8709(V037)

Tetanus-diphtheria-polio (Td-polio)

After childhood primary vaccine series every 10yrs

8709

(V037)

Polio (IPV)

After childhood primary vaccine series every 10yrs

V032

Influenza

(contains egg products)

Every year

Recommended for certain groups

Free for some groups, charge for others

10$ or

8791

(VO48)

Measles

Mumps

Rubella

Given as MMR Serology Measles:

Given for Health Care people Serology Mumps:

Live vaccine and may interfere with Mantoux Serology Rubella

8670 (VO68)

Hepatitis A

Vaqta, Havrix1440 or Avaxim

All brands equal and interchangeable

Dose 1 (gives protection for 12 months)

50$ adult

25$ child

Dose 2 after 6months gives protection at least 10-20 yrs

50$ adult

25$ child

Hepatitis B

Energex B or Recombivax

Dose 1 gives some protection

28$ adult

14$ child

Dose 2 after 28 days gives protection for 12 months

28$ adult

14$ child

Dose 3 after 6 months or more protects for life

(health care workers are suggested to get immunity level checked with a blood test )

28$ adult

14$ child

Twinrix

Hep A+B

Dose 1 gives some protection but needs 2 nd dose

52$ adult

26$ child

Dose 2 after 28 days gives protection for 12 months

52$ adult

26$ child

Dose 3 after 6 months or more protects Hep B for life

(health care workers are suggested to get immunity level checked with a blood test )

Hep A for at least 10-20 yrs

52$ adult

26$ child

Typhoid

(inactivated)

Typhoid (inject) protects 3 yrs

Typhim VI or Typherix protects 3 yrs

25$

Typhoid

(live vaccine)

Typhoid (oral) Ty21a Given as 4 pills which must be taken days 0,2,4,6 and protect 7yrs

25$

Yellow fever

Live vaccine

Do not give in children under 9 months (review) or Immunocompromised

Use with caution in elderly. Certificate valid 10days after shot and for 10 yrs Please write serial no.____________________

60$

Meningitis

Menume

Protects against Meningitis A/C/W/Y

Good for 3 yrs

85$

Rabies

Immovax

Recommended for travelers going to high risk areas.

3 doses give some protection but travelers still must seek medical attention for suspicious bites and 2 more doses of vaccine after bite

Dose 1

Prescription

Dose 2 after 7 days

Prescription

Dose 3 after 21 days from first

Prescription

Chicken pox (Varicella)

Varivax 3

Most adults are immune,. check serology: Immune

One dose for children, Non-immune

Two doses for adults 4-8 wks apart

Prescription

Tuberculosis Test

Mantoux Test Step 1 (20$ per step test)

Planted______Read_______,_______mm

Mantoux Test Step 1 (20$ per step test)

Planted______Read_______,______mm