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
Your Website
I am a previous customer
Another Website
Company
Occupation
Primary Care Physician
Phone
Addresss
Type of Service(s)  Requested
Office Consultation $75.    Appointment must be made
Mail or E-mail Consultation  $75        SEND BY
prepayment required
Mail
Via E-Mail
Vaccines for Travel Only-   Administration fees  plus cost of vaccines.  Client knows which
vaccines he wants
Vaccines for Non-Travel Only- Administration fees plus plus cost of vaccines.  May Skip the Travel Section of
the Questionnaire
Prescriptions for Travel Only $25
PPD (Tubercullosis Screening)  $25
Travel Information -Please skip if not Traveling
Please list the countries you
are traveling to and the length
of stay in each country
Departure Date
Return Date
Reason for Travel
Tourist
Mission
Business
 Visiting Friends and Relatives
Other
Accomodations= Check all that apply
Hotel
Family/Home
 Camping
Youth Hostel
Cruise
Check all that apply.  I plan to:
Visit Rural Areas
Visit only tourist areas
 Go bicycling
Scuba dive
 Travel to or climb to high altitudes
Drive car or motor scooter
Go hiking or backpacking
Swim in fresh water lake or stream
 Swim in Ocean
Vaccines and Prescriptions
Requesting prescription for Malaria:
YES
Vaccines- If you already know what you
want please list here
Medications- If you already know what
you want please list here
Medical History
None
Current or Previous Medical Conditions
Current Medications
None
Please Check Yes or No. Use the additional comments area 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 Guillian-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?
Additional Comments
PAYMENT
Only complete if requesting Internet services such as Travel Consultation by email , or mail,
or prescription services. This is not credit card processing- information is sent to our
office. If you prefer, you may call our office and provide the credit card information.
Credit Card Number
Type of Credit  Card
Expiration Date
Name on Credit Card
Amount
The above information is true and accurate to the best of my knowledge. I understand that
payment is expected at time of service with check, cash, or credit card.
Relationship
to Patient
Print Name
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