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______________________________________________________ TRAVEL INFORMATION 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, other_____________________________________ Please check if allergic to any of the following: ( ) eggs, ( ) yeast, ( ) gelatin, ( ) latex, ( ) animal protein, ( ) feathers, ( ) bee stings, ( ) lactose, ( )other______________________________________________________
Name: ___________________________________________________________ Date: ______________________ Question 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 problem? Do you have high blood pressure? Are you on Do you have severe kidney problems? medication? 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- Barre syndrome? 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 or Rho-gam? yes, please describe
Do you have diabetes? If yes, do you take Do you have a history of depression or insulin? Yes____ No____ psychiatric disorders? 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 Women only: 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 Chicken Pox Immune Globulin Measles, Mumps, Rubella Pneumonia Meningitis Tetanus/diphtheria/pertussis Hepatitis A Hepatitis B Japanese Encephalitis Yellow Fever 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, [email protected] 2University of the Western Cape, Bellville, South Africa, [email protected] 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?
TRAVEL HEALTH SERVICES, LLC