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Careworks convenient healthcare
Careworks Convenient Healthcare
Name:___________________________________Date of Birth: _____/_____/_____
Home Phone:_____________________________Cell Phone:____________________________
Email Address: __________________________________
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):
Where will you be staying (check all that apply)?
What type of accommodations will you be staying in (check all that apply)?
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):
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:
3. _________________________________________________________________________ List current medication with dosage and frequency:
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):
__________ Tdap (Adacel)
__________ Tetanus/Diphtheria booster
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
Any bad reaction/side effect from any vaccination?
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?
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?
to prevent traveler’s diarrhea?
aspirin therapy? (children & adolescents)
medications for emotional problems?
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.
IDENTIFICATION DATA: A 78-year-old male. REASON FOR CONSULTATION: The patient is scheduled for total hip replacement, who has hypertension, hypercholesterolemia, possible peripheral vascular disease, previous smoker. He is a patient of Dr. John B. Luster. Surgery is scheduled for August 1, 2006. HISTORY OF PRESENT ILLNESS : I saw the patient today, who is scheduled for total hip re
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