Preventive Medicine & Environmental Health
l University of Kentucky Hospital A.B. Chandler Medical Center
l UK HealthCare Good Samaritan Hospital
l UK HealthCare Ambulatory Services
l UK Dental and Oral Heatlh Clinics
PRE-TRAVEL QUESTIONNAIRE (Patient Label Here)
SECTION ONE - PERSONAL INFORMATION AND ITINERARY
Name: Today's date:
Who referred you to our clinic?
Age: Date of departure: Date of return:
Purpose of travel: Pleasure / vacation Religious Medical
Business/education
(Company name / affiliation)
How many times have you traveled to developing countries:
Never Once Twice Three times Four or more times
To which countries have you been?
Countries on itinerary (in order of travel and note major forms of transportation):
COUNTRY MODE OF TRANSPORTATION EXPECTED DURATION OF STAY
1.
Cities: (a)
(b)
(c)
2.
Cities: (a)
(b)
(c)
Additional countries anticipated for future travel:
Check all that apply to your travel plans.
Major resort hotels Staying with a family Rural travel
Small hotels Cruise ship Outdoor activities
Youth hostel Camping Organized tour group
Rented foreign home Safari Other (please specify)
M8-0465
HP-0116 3/6/18 Page 1 of 6
l University of Kentucky Hospital A.B. Chandler Medical Center
l UK HealthCare Good Samaritan Hospital
l UK HealthCare Ambulatory Services
l UK Dental and Oral Heatlh Clinics
PRE-TRAVEL QUESTIONNAIRE (cont.) (Patient Label Here)
Will you be participating in physically strenuous activities (skiing, mountain climbing, SCUBA diving,
hiking, activities at above 5,000 feet?) No Yes
If yes, have you been involved in conditioning activities? No Yes
SECTION TWO - PERSONAL HEALTH ISSUES
Allergies Significant medical conditions
Bee / insect stings Altitude sickness HIV / AIDS
Seasonal Anemia Immune deficiency
Thimerosol / mercury Asthma Liver disease
Eggs Blood clots Lung disease
Require oxygen
Drugs Blood transfusion in
the last year
1. Malaria
2. Cancer Motion sickness
No known allergies Depression or other Myasthenia gravis
psychiatric disorder
Parasitic disease
Allergy medications: Diabetes (H)
Physically challenged
1. Insulin dependent
Psoriasis
2. Eye disease
3. Stomach / intestinal Pregnancy (H)
problems Due date:
G6PD deficiency Sickle cell disease
Hearing impaired Splenectomy
Heart disease Past travel illness with
jaundice
Require oxygen
Pacemaker Thymus disease
Hypertension Traveler's diarrhea
Hepatitis Other:
NONE OF THE ABOVE
HP-0116 3/6/18 Page 2 of 6
l University of Kentucky Hospital A.B. Chandler Medical Center
l UK HealthCare Good Samaritan Hospital
l UK HealthCare Ambulatory Services
l UK Dental and Oral Heatlh Clinics
PRE-TRAVEL QUESTIONNAIRE (cont.) (Patient Label Here)
Do you currently take any medications or food supplements? No Yes
If yes, please list the name of the medication, indication, and dose. List both prescription and over-the-counter
medications.
Have you received a transfusion of blood products in the last 6 months?
If yes, indicate the blood type and date:
SECTION THREE - IMMUNIZATIONS
Usual childhood immunizations No Yes
Vaccinations as an adult No Yes If yes, please indicate below which ones
and most recent date.
Vaccination Date Vaccination Date
Hepatitis A Hepatitis B
Dose 1 Pneumovax
Dose 2 Influenza
MMR booster TB skin test
Tuberculosis BCG Polio
Typhoid Japanese encephalitis
Oral Meningococcus
Injection Tetanus / diphtheria
Rabies Yellow fever
Cholera Immune globulin
Plague Varicella
Other
Do you live or work closely with anyone who has an immune deficiency? No Yes
Have you used malaria prophylaxis medications in the past? No Yes
If yes, please indicate below which ones. Please note any side effects / adverse reactions.
Side effects? Side effects?
Mefloquine (Lariam) Primaquine
Chloroquine (Aralen) Doxycycline
Hydroxychloroquine (Plaquenil) Maloprim
Proguanil Malarone
HP-0116 3/6/18 Page 3 of 6
l University of Kentucky Hospital A.B. Chandler Medical Center
l UK HealthCare Good Samaritan Hospital
l UK HealthCare Ambulatory Services
l UK Dental and Oral Heatlh Clinics
PRE-TRAVEL QUESTIONNAIRE (cont.) (Patient Label Here)
THE FOLLOWING SECTIONS TO BE COMPLETED BY PROVIDER
SECTION FOUR - COUNSELING
PRE-TRIP COUNSELING AREAS
Travel insurance Motion sickness
Travel medicine kit Jet lag / time zone adjustment
Melatonin
Conditioning for athletic trip Arrangements for medical needs
Carry-on medications Dental status
IN-FLIGHT COUNSELING AREAS
Effects of alcohol / caffeine at high altitude Hydration (low humidity)
In-flight activity to reduce clotting Lumbar and neck support
DESTINATION COUNSELING AREAS
Sun protection Insect precautions
SPF 30 UVA & UVB Picardin %
Sunglasses DEET %
Traveler's diarrhea Permethrin
Food & water precautions Auto safety
Medical attention for symptoms e.g. rentals, laws, what side of road
Water precautions Local laws and customs
Blood supply in developing countries Maps reviewed
Safe sex precautions Malaria
Altitude Yellow fever
Other
POST-TRIP COUNSELING AREAS
Follow-up appointment indicated Indications for follow-up:
Persistent fever or diarrhea
Follow-up TB skin test indicated
New persistent cough
Unexplained weight loss
Night sweats
HP-0116 3/6/18 Page 4 of 6
l University of Kentucky Hospital A.B. Chandler Medical Center
l UK HealthCare Good Samaritan Hospital
l UK HealthCare Ambulatory Services
l UK Dental and Oral Heatlh Clinics
PRE-TRAVEL QUESTIONNAIRE (cont.) (Patient Label Here)
SECTION FIVE - ASSESSMENT AND RECOMMENDATIONS
Height: Weight: Temp: Pulse:
Syringe / medication letter given: Not indicated Yes No Date sent:
Adequate prescription medications for trip: Yes Not applicable No
Prescriptions written Referred to primary physician
Post-trip evaluation recommended? No Yes Date:
(Recommended for trip over 3 months in duration or for specific health problems.)
IMMUNIZATIONS (usual adult doses)
1. Hepatitis A vaccine (1.0ml IM) 11. Rabies (0.1ml IM days 0, 7,21/28)
2. Hepatitis A vaccine peds (0.5ml IM) 12. Tetanus / diphtheria (0.5 ml IM)
3. Hepatitis B (1.0 ml days 0, 30,180) 13. TB skin test
4. Influenza (0.5 ml IM) 14. Typhoid b
5. Japanese encephalitis (days 0, 28) Typhom Vi (0.5ml IM)
6. MMR booster a (0.5ml SC) Orala (1po QODx4)
7. Meningococcus (0.5ml IM) 15. Varicellaa (0.5cc sub-q; second 4-8 weeks)
8. Pneumovax (0.5 ml IM/SC) 16. Yellow fever a,c (0.5 ml SC)
9. Polio (0.5ml IM) 17, Other
10. Cholera (Vaxchora)a None
a. Live vaccine b. Contraindicated if allergic to thimerosol c. Contraindicated if allergic to eggs.
MALARIA PROPHYLAXIS
No prophylaxis recommended
Mefloquine (Lariam) 250 mg/week (Rx # )
*(Not for use with beta blockers calcium channel blockers, pregnancy, history of Epilepsy or psychiatric problems)*
Chloroquine (Aralen) 500 mg/week (Rx # )
*(Lessen side effects by taking with meals or divided into twice weekly doses. Contraindicated with psoriasis)*
Doxycycline (Vibramycin) 100 mg/day (Rx # )
*(Not for use with pregnancy, children younger than 8 yrs. Do not take with dairy products. For women of child bearing age: advise to use reliable birth control
methods while taking Malaria prophylaxis,)*
Malarone (Atovaquone 250 mg/Progvanil 100 mg) (Rx # )
Other (Rx # )
HP-0116 3/6/18 Page 5 of 6
l University of Kentucky Hospital A.B. Chandler Medical Center
l UK HealthCare Good Samaritan Hospital
l UK HealthCare Ambulatory Services
l UK Dental and Oral Heatlh Clinics
PRE-TRAVEL QUESTIONNAIRE (cont.) (Patient Label Here)
TRAVELER'S DIARRHEA PROPHYLAXIS
No prophylaxis recommended
Bismuth Subsalicylate (Pepto Bismol) up to 2 tabs QID
*( Not to be taken with aspirin hypersensitivity, history of gout, use of anticoagulants or Hypoglycemic agents. Not recommended for children.)*
Probiotic
Other:
SELF TREATMENT FOR TRAVELER'S DIARRHEA (H)
None recommended
Pepto-Bismol and Imodium AD
TMP/SMX DS BID x 3-5 days (Rx # )
Ciprofloxin 500 mg BID x 3 days (Rx # )
(Not with theophyiline, seizure disorder, age < 18)
Levofloxacin 500 mg qd x 3 days (Rx # )
(Contraindications per cipro)
Doxycycline 100 mg BID x 3 days (Rx # )
(Not with age < 18, sun exposure)
Loperamide 4 mg loading, 2 mg after each unformed stool (8 mg/d max)
Azithromycin 500 mg
RiFaximin 200 mg q8 x 3 days
Other
OTHER MEDICATIONS
Acetazolamide 125 mg
Diflucan 150 mg (one for yeast infection)
Scopolamine patch (1.5mg), apply q3 days for motion sickness
Epipen, use as directed for allergic reaction
Other
OTHER RECOMMENDATIONS
HANDOUTS PROVIDED:
Travel Insurance Traveler's Thrombosis Jet Lag
Insect Precautions Traveler's Diarrhea Food and Beverage Precautions
Safety and Security Motion Sickness Altitude Sickness
Sun Protection Zika virus TRAVAX Printout
Other: Other:
Session: Single/group for minutes.
Completed by: Date:
Reviewed history and recommendations - concur
HP-0116 3/6/18 Page 6 of 6
