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Please fill out this form & bring it with you to your
Travel Clinic Appointment and bring all current
medication to your appointment. Also bring any
immunization records you may have.
Name:_______________________________DOB:___________ Male or Female Address:_________________________________ Social Security:___________________ Home phone __________________ Work phone_________________ Primary Clinic ___________________________ Primary Provider__________________________ Itinerary:________________________________________________ Rural or Urban or Both Date:___________________Date of Departure:__________________________ Length of Stay_________________ Immunizations
Problem**
Have you ever fainted from having your blood drawn or from an injection? Have you ever had a fever reaction to vaccination? Have you ever had any bad reaction or side effect from any vaccination? Have you every had hepatitis A or B vaccine? Do you live (or work closely) with anyone who has AIDS, an AIDS-like Varicella, Smallpox, Influenza (FluMistTM) condition, any other immune disorder or who is on chemotherapy for cancer? Do you have a family history of immunodeficiency? Have you received any injection of immune globulin or any blood product General Medical
Problem**
Do you have a medical condition that warrants maintenance medications or physician follow-up? Do you have a medical condition that is stable now, but that may recur while traveling? Have you had a fever in the past 48 hours? Td, Influenza, Meningococcal, Oral typhoid, Pneumococcal (PPV) Are you pregnant* or might become pregnant on this trip? MMR or components, Oral typhoid, Smallpox, Varicella, Yellow Fever, Influenza (FlumistTM), Oral Cholera (Muracol ®); Doxycycline and other antibiotics. For other immunizations weigh the theoretical risk of vaccination against the risk of disease. Do you have AIDS, an AIDS-like condition, any other immune disorder, MR or components, Oral Typhoid, Smallpox, Rabies, Varicella, Yellow Fever, Oral Cholera (Muracol ®), Influenza (FluMistTM) 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? Do you have bowel conditions such a 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 dream and/or nightmares? 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? Medications
Problem**
Are you taking or will you be taking:
Quinine, quinidine, or medications for a cardiac conduction defect?
Chloroquine, mefloquine, or proguarill to prevent malaria? Oral Thypoid, Oral Cholera (Mutacol®) MMR or components, Oral Typhoid, Varicella, Yellow Fever, Influenza (FluMistTM) Pepto-Bismol® to prevent traveler’s diarrhea? Aspirin therapy? (children & adolescents) Allergies
Problem**
Are you allergic to:
DTaP (Tripedia®), DT, Td, Hib (TriHIBitTM, HibTITER® multidose), Japanese Encephalitis, Hepatitis b, Hep. A/B (Twinrix®), IG, Influenza, Meningococcal (multidose), Rabies (RVA, RIG), Tetanus IG (Hyper-Tet®) Aminoglycoside antibiotics? (streptomycin, neomycin, kanamycin, gentamicin) Hepatitis A/B (Twinrix®), Influenze, IPV, MMR or components, Rabies [HDCV and PCEC], Varicella, Smallpox, PEDIARIXTM Influenza (Fluvirin®), IPV, Smallpox, PEDIARIXTM Hep A, Hep B, Hep A/B (Twinrix®), COMVAXTM, DTaP, Td, Rabies (RVA), Anthrax, Pneumoccoccal (PVC), Oral Cholera (DukoralTM) 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, Oral Cholera (Mutacol®) Influenza, Rabies (PCEC), Yellow Fever, MMR or components Varicella, Japanese Encephalitis, MMR or components, DTaP, Yellow Fever, Rabies (PCEC), Influenza (Fluzone), Oral Typhoid Are you hypersensitive to beef protein, soy, casein, lactose, phenol, or IPV, Meningococcal, Typhoid, Rabies, DTaP, **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. International Travel Questionnaire.~ts 6/18/2013 Please note below any diseases you have had, with dates if possible. Disease name
Had disease – list date if possible
Please record the dates you received any of the following Immunizations (You may have to check with previous health care providers to get all of this information.) ROUTINE IMMUNIZATIONS
OTHER IMMUNIZATIONS

Have you taken medication in past for Malaria: Y N
Side effects?___________________________________________________________________________________
Please list any existing medical conditions: (example: diabetes, heart disease, or lung disease) _______________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

List all medications
you currently are taking, either prescriptions or over-the-counter: ________________________
_____________________________________________________________________________________________
List any Allergies you have: ______________________________________________________________________
Are you pregnant or might you become pregnant on this trip? Yes / No
If pregnant, how many weeks?_________
Are you breast feeding? Yes / No
Are you prone to motion sickness? Yes / No

International Travel Questionnaire.~ts 6/18/2013 Diphtheria, Tetanus, Pertussis (DTaP/DTP) if <7 yrs of age
Hepatitis A
Tetanus, Diphtheria (Td) if >7 yrs of age Prophylactic Medication
Indication
Required
Recommended
Medication/Rx given

Provider Signature:______________________________________Date:_________________________
Patient Consent: I have read the written information given to me and I have discussed with my doctor and/or nurse the
benefits and risks of the vaccines noted above which are required and/or recommended for my protection while traveling
abroad. I have had a chance to ask questions which were answered to my satisfaction. I request that these vaccines be
given to me or to the person named below for whom I am authorized to make this request. I hereby authorize and request
you to furnish this record to:__________________________.
Relationship to patient___________________________Signature____________________________Date:_________
Witness____________________________________________
Minor surgery complete/review with provider/provider signature for order/file in chart/copy to patient by minor surgery International Travel Questionnaire.~ts 6/18/2013 Teaching: (date done) ______________ ____ Done previously ____ Brief review
Handouts given to the patient
– check all that apply:
 Travelers Medical Record

Other handouts given to the patient

Vaccine information sheets:
Work-up prepared by_______________________
International Travel Questionnaire.~ts 6/18/2013

Source: http://www.hutchhealth.com/files/4113/7160/0726/InternationalTravelQuestionnaire0113HH.pdf

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8401 W. DODGE RD., SUITE #115, OMAHA, NE 68114; 1-800-222-1222; (402) 955-5555 Steven A. Seifert, MD, Medical Director Nebraska Regional Poison Center _____________________________________________ The Emergency Department is often the front line in dealing with significant toxic exposures. Here’s an update. 1) We’ve had a name and sponsorship change. We are now the Nebraska Regional Po

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