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Microsoft word - final ths health history.doc
TRAVEL HEALTH SERVICES, LLC
International Travel Questionnaire
PERSONAL DATA (please print clearly)
Name: ________________________________________________________________ Date: _________________
Address: ____________________________________ City: ___________________ State:______ Zip:________
Home Phone: (____)_________________ Cell: (____)__________________ Work: (____)________________
Birthdate: _____________ Sex: ( ) M, ( ) F Weight if < 100 lbs____ Employer:_____________________________
Emergency Contact/ relationship: _____________________________________________________Phone:____________
Referred by: ( ) Physician____________________________________________, ( ) Website, ( ) Health Dept.,
( ) Friend/Family, ( ) Other______________________________________________________
List all travel dates and countries in order of dates traveling:
1. Date: __________ From: _________________________ To: ________________________ Length of stay:________
2. Date: __________ From: _________________________ To: ________________________ Length of stay: ________
3. Date: __________ From: _________________________ To: ________________________ Length of stay: ________
4. Date: __________ From: ________________________ To: _______________________ Length of stay: ________
5. Date: __________ From: _________________________ To: ________________________ Length of stay: _______
Reason for Travel: ( )Business, ( )Tourist, ( )Student, ( )Missionary, ( )Other______________________
Accommodations: ( )Hotel, ( ) Family/Friends Home, ( )Cruise, ( )Other_______________________________
Do you plan to visit only tourist’s areas or major cities?
Do you plan to visit rural areas?
Do you plan to visit rural areas during evening or nighttime hours?
Do you plan to go hiking or backpacking?
Do you plan to travel to high altitudes?
Do you plan to go swimming?
If yes: ( ) Chlorinated Pool, ( ) Fresh Water Lake or Stream, ( ) Ocean
Do you plan to scuba dive? Certified?___________
If yes: When is air travel scheduled after the first dive?________________________________
MEDICATION AND ALLERGY INFORMATION
List Current Medications (including oral contraceptives and blood pressure medicine): ______________________
Please check if allergic to any of the following medications: ( )Neomycin, ( )Penicillin, ( )Gentamycin,
( )Sulfa, ( )Streptomycin, ( )Polymixin, ( )Amphotericin B, ( )other________________________________
Please check if allergic to any of the following vaccine components: ( ) thimerisol / mercury, ( )phenol,
( ) aluminum hydroxide, ( ) 2-phenoxyethanol, ( ) formaldehyde, ( ) aluminum, ( )chlortetracycline,
Please check if allergic to any of the following: ( ) eggs, ( ) yeast, ( ) gelatin, ( ) latex, ( ) animal protein,
( ) feathers, ( ) bee stings, ( ) lactose, ( )other______________________________________________________
Name: ___________________________________________________________ Date: ______________________
Yes No Question
Do you have a medical condition that warrants
Do you or any person you are in close
regular medication or physician follow-up? If
contact with take cortisone, prednisone,
yes, please list:
steroids, chemotherapy (anti-cancer drugs)
or radiation therapy?
Do you have heart problems? Do you have a
Do you, or any person you are in close
cardiac arrhythmia or irregularity?
contact with, have cancer, leukemia,
HIV/AIDS, or any other auto immune
Do you have high blood pressure? Are you on
Do you have severe kidney problems?
Do you have bleeding problems, take
Do you have G6PD deficiency?
coumadin or anticoagulants or aspirin?
Do you have lung disease, asthma, chronic
Do you have an active nerve condition? Do
bronchitis, emphysema, or shortness of
you have a history of seizures or Gullian-
Do you have a stomach or bowel condition,
Have you had your thymus gland removed,
such as irritable bowel or frequent
or a history of problems with your thymus,
constipation or diarrhea? Do you use
such as myasthenia gravis, DiGeorge
medication to reduce stomach acid daily?
syndrome or thymoma?
Do you have any skin condition such as
Have you ever fainted from an injection or
psoriasis, eczema or shingles?
from having your blood drawn?
Do you experience insomnia or nightmares?
Are you sick today?
During the past three months, have you
Have you ever had a serious reaction after
received a transfusion of blood or plasma, or
receiving a vaccination, such as hives, rash,
been given a medicine called immune globulin
wheezing, difficulty breathing, or shock? If
yes, please describe
Do you have diabetes? If yes, do you take
Do you have a history of depression or
insulin? Yes____ No____
Do you have tuberculosis? Have you ever
Have you received any vaccinations in the
tested positive for tuberculosis?
past 4 weeks? If yes, please list:
When at altitudes above 6,000 feet, have you
ever had headache, dizziness or felt short of
Are you pregnant or plan to get pregnant in
the next 3 months?
Have you had hives or urticaria?
PREVIOUS IMMUNIZATIONS *IMPORTANT! Please print “c” for childhood series completed or enter year vaccinated
Measles, Mumps, Rubella
Have you ever taken malaria pills? ( ) Yes, ( ) No. If yes, did you have any side –effects?
The above information is accurate to the best of my knowledge. I understand that insurance may not cover travel
immunization services and I am responsible for all fees due at time of service. Travel Health Services is not a
Medicare provider and does no insurance or filing of claims. Payment is due at the time of service by credit card,
cash or check. I understand that I will be given an immunization record with all vaccines received and that I am
responsible for keeping this in a safe place and keeping records up to date. Inactive records are kept on file for 3
years. Your files are confidential.
May we send your primary care physician a copy of your immunization record?
( ) Yes
( ) No
Physician’s name & address: ____________________________________________________________________
Traveler/patient signature: ________________________________________________________ Date: _______________
Travel Health Nurse: _____________________________________________________________ Date: ________________
Biodiversity and Indigenous Knowledge in South Africa: 1University of South Africa, Pretoria, South Africa, firstname.lastname@example.org 2University of the Western Cape, Bellville, South Africa, email@example.com The Convention on Biological Diversity (CBD) emphasizes conservation of biodiversity, the sustainable use of its components and the fair and equitable sharing of benefits arising from geneti
TRI-VALLEY July 2010 Help-line Tri-Valley receives many questions from area seniors, younger people with disabilities and caregivers and has created this monthly Help-line column to provide some assistance. We are also available five days a week to answer individual questions. Seniors & Safer Drinking Q: Should older people be careful about their alcohol intake?