Travel Clinic Screening Questionnaire
Name: ______________________________________________________ DOB: ________________ Date: ________________ Allergy History Are you allergic or hypersensitive to any of the following? (Check all that apply)
Any other medication allergies, please list: _______________________________________________________________________________________ Have you ever had a bad reaction or side effect from any vaccination?
If yes, please explain: ___________________________________________________________________________________________ Medications Please list all the medications/injections you are currently taking, including over the counter medications and vitamins and minerals: ________________________________________________________________________________________________ ________________________________________________________________________________________________ Medical History Have you ever fainted from having your blood drawn or from an injection?
Do you live (or work closely) with anyone who has cancer, HIV/AIDS, any
Do you have cancer, HIV/AIDS, or any other immune disorder?
Have you taken steroids (i.e. Prednisone, Medrol) within the past 6 months?
Have you had any chemotherapy in the past 6 months?
Have you had or do you currently have any of the following: [ ] Fever in the past 48 hours
[ ] Low platelet count/coagulation disorder
Are you pregnant? [ ] yes [ ] no
Date of last menstrual period _______________ [ ] post
menopause Are you planning to become pregnant within the next year?
Length of stay: _______________________________________________
Destination(s): (Please list all the countries you will be visiting in the order that you will be visiting them) ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ CLINIC USE ONLY [ ] Reviewed Travel Clinic Screening Questionnaire [ ] Reviewed allergies and adverse reactions [ ] Travax report run and printed [ ] Print Malaria/Yellow Fever map if risk patient [ ] Informed female travelers not to become pregnant for 6 months after leaving malarious area [ ] Drug-drug interaction run [ ] Reviewed Travax report with traveler [ ] Reviewed book and VIS sheets with traveler. Side effects of vaccines and medications reviewed with traveler [ ] Vaccines administered and documentation completed [ ] Informed female travelers to not become pregnant for 3 months after a live vaccine [ ] Malaria Rx given to patient:
[ ] High Altitude prophylaxis indicated:
[ ] Oral Typhoid vaccine indicated and Rx given [ ] Traveler’s Diarrhea treatment reviewed and Rx given:
[ ] Bee/Wasp allergy documented and Rx given:
[ ] Those with syringe requirements, note of exemptions given [ ] Yellow book completed [ ] Copy of vaccine schedule given to traveler [ ] Pt understands risk of disease if unvaccinated
A first experiment in algorithmic graph theoryA graph is called “properly (2-)colorable” if there is a red/blue coloring of the nodessuch that each of the edges is “mixed” :that is, such that the endnodes of each edgehave different colors. Note that this is an existential graph property; as algorithmic graphtheorists, we are therefore compelled to investigate this property by writing a
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