Travel clinic questionnaire web.pdf

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:
Please list all the medications/injections you are currently taking, including over the counter medications and vitamins and
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 Other: _______________________________________________________________________________________________ WOMEN ONLY

Are you pregnant? [ ] yes [ ] no
Date of last menstrual period _______________ [ ] post menopause Are you planning to become pregnant within the next year? ITINERARY
Length of stay: _______________________________________________
Destination(s): (Please list all the countries you will be visiting in the order that you will be visiting them)

[ ] 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



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