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Careworks convenient healthcare

Careworks Convenient Healthcare
Pre-Travel Questionnaire
Name:___________________________________Date of Birth: _____/_____/_____ Home Phone:_____________________________Cell Phone:____________________________ Home Address:_________________________________________________________________ _____________________________________________________________________________ Email Address: __________________________________ Marital Status:____________________Religion:____________________Race:______________

Trip Itinerary:
Departure Date: __________________________________
Length of Stay – Exact # of Days_____________________days Please list all countries and cities (if known) that you will visit on this trip in the order of travel:
6. ___________________________________
What type of flight will you be taking?
Direct flight_____I will be stopping in/have layover in___________________________________
Have you traveled to any developing country before? Yes____ No____
Have you traveled to this/these destinations before?

Purpose of trip (check all that apply):
Other:__________________________________
Where will you be staying (check all that apply)?
Other:__________________________________
What type of accommodations will you be staying in (check all that apply)?
Other:__________________________________ Who will you be traveling with?

What type of recreation will you be doing (check all that apply)?

Allergies (list all):
Bee stings Latex Food - Please list food allergies:_________________________________________________ Medications – Please list medication allergies:______________________________________
Do you have any current or past medical history of (check all disease/conditions you may have):

Blood/Cancer Environmental
Neurologic/psych
Heart/Lung
Stomach Musculoskeletal
Immune System
Endocrine
Other:________________________________________________________________________
Do you live or work closely with anyone who has history of immune system deficiency or who is on
chemotherapy? Yes____ No____
Have you received a blood transfusion and/or immune globulin in the past 12 months? Yes____ No____
Have you received any prednisone or steroids in the past 12 months? Yes____ No____
List any surgeries with date (month/year) if possible:
1. _________________________________________________________________________ 2. _________________________________________________________________________ 3. _________________________________________________________________________
List current medication with dosage and frequency:
1. _________________________________________________________________________ 2. _________________________________________________________________________ 3. _________________________________________________________________________ 4. _________________________________________________________________________
Date of last medical exam: _____/_____/_____
Date of last dental exam: _____/_____/_____
Women:
Are you currently pregnant or trying to get pregnant? Yes____ No____
Are you breastfeeding? Yes____ No____
Date of last menstrual period: _____/_____/_____
Date of last GYN exam: _____/_____/_____
Type of birth control (please check):
Have you had any reactions in the past to any vaccines:
Do you have any allergies to any vaccines or components? Yes____ No____
Immunization history (please list all dates or attach record):
Childhood immunizations:

Travel Immunizations:
__________ Tdap (Adacel)
__________ Tetanus/Diphtheria booster
__________ Varicella
Reminders to bring with you:
1. Please bring current vaccine record with you. If you cannot find your vaccine record, you may
c. College/university health office d. High 2. If possible, review CDC travel information (www.cdc.gov/travel) for the countries to be visited. Write down any questions or concerns you may have, and bring them with you to your appointment. International Travel Medical Questionnaire – 2007-2008

Immunizations

Any bad reaction/side effect from any vaccination?
General Medical
Problem*
Do you have AIDS, an AIDS-like condition, any other immune disorder, leukemia, or cancer? MMR or components, Oral typhoid, Smallpox, Rabies, Varicella, Yellow Fever, Influenza (FluMist®), MMRV, Zoster Vaccine Live (Zostavax®) Have you had your thymus gland removed or a history of problems with your thymus, such as myasthenia gravis, DiGeorge syndrome, or thymoma? Do you have severe thrombocytopenia (low platelet count) or a coagulation disorder? Have you ever had a convulsion, seizure, epilepsy, neurologic condition, or brain infection? Do you have any stomach conditions? Oral typhoid, Mefloquine, Doxycycline, Bowel confition such as diarrhea or constipation? Have you ever had hepatitis or yellow jaundice? Do you have a history of psychiatric problems? Do you have a problem with strange dreams and/or Have you or a member of your household ever been diagnosed with eczema or atopic dermatitis (e.g., Itchy, red, scaly rash lasting > 2 weeks that often comes and goes)? Cardiac disease, with or without symptoms? Smallpox, Influenza (FluMist®)

Medications

Problem*
ARE YOU TAKING OR WILL YOU BE TAKING:  medications for a cardiac conduction defect?  chloroquine, mefloquine, or proguanil to prevent malaria?  proguanil to prevent malaria?  Pepto-Bismol® to prevent traveler’s diarrhea?  aspirin therapy? (children & adolescents)  medications for emotional problems?
Allergies
Problem*
ARE YOU ALLERGIC TO:  any medications? Diamox®, Fansidar®, Penicillin, Sulfa DT (multi-dose), Tetanus toxoid (multi- dose; booster), Influenza (Fluzone (Only vaccines containing more than a trace amount Hepatitis A/B (Twinrix®), Influenza, (streptomycin, neomycin, kanamycin, gentamicin) IPV, MMR or components, Rabies (HDCV and PCEC), Varicella, Zoster Vaccine Live (Zostavax®), Smallpox, PEDIARIXTM, MMRV, TBE  aluminum or aluminum hydroxide? Hep. A, Hep. B, Hep. A/B (Twinrix®), COMVAXTM, DTaP, Td, Rabies (RVA), Anthrax, Pneumococcal (PVC), Tdap Hep. A (Havrix®), Hep. A/B (Twinrix®), IPV, DTaP (InfanrixTM , PEDIARIXTM),  bee stings or history of hives or urticaria? Hep. B, Hep. A/B (Twinrix®),PEDIARIXTM Influenza, Rabies (PCEC), Yellow fever, Are you hypersensitive to gelatin? Varicella, Japanese encephalitis, MMR or Rabies (PCEC), Influenza (Fluzone), Oral Typhoid, MMRV, Zoster Vaccine Live ( Are you hypersensitive to beef protein, soy casein, IPV, Meningococcal, Typhoid, Rabies, lactose, phenol, or formaldehyde? DTaP, Pneumococcal (PPV), Anthrax, Smallpox, Tdap, MMRV, Rotavirus, TBE

*Note: Any “problem” listed above may be a contraindication or merely a precaution that warrants further discussion between the health care
provider and patient. The “problem” list is not all-inclusive but is representative of common issues that arise in a pre-travel consultation.

SIGNATURES:
___________________________________ ___________________________________

Source: http://www.careworkshealth.com/cwh/geisinger/pretravel-questionnaire.pdf

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