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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:
___________________________________________________________________________________________
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 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)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

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


______________________________________________________

Source: http://www.mercy-chicago.org/TravelClinicQuestionnaire.pdf

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