Infectious Diseases Consultants of Oklahoma City
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1 Infectious Diseases Consultants of Oklahoma City Travel Clinic Questionnaire Patient Name:. DOB: / /. q first visit q return visit Adress: Phone: Primary Purpose of travel: q Business q Personal q Mission q Other Destinations (list countries in the order you will be visiting them.) Country Urban Rural Length of Stay Purpose of visit (check one or both) 1. q q 2. q q 3. q q 4. q q 5. q q 6. q q Date of Departure from the United States / / Date of Return to the United States / / Activities: Will you be undertaking any of the following activities? q Hiking q High altitude activities q Anthropology q Cave Exploring q Working in a medical setting q Biology q Handling Animals q Swimming in local bodies of water q Safari q Archaeology q Bicycling q Other Lodging (one or more) q Affluent Hotels q Hostels q Staying with a local resident/family q Camping/Adventure Travel q Dormitory q Other
2 Medical History: Do you have a history of: q Myasthenia Gravis q Diabetes q Chronic Kidney Disease q Heart Disease q Cancer q Chronic Lung Disease q Are you taking chemotherapy now? q Asthma q Chronic Steroid Therapy q HIV or AIDS q Immune disorder q Chronic Hepatitis C q Cystic fibrosis q Chronic Liver Disease q Are you on blood thinners? q Epilepsy q Psychiatric disease q Removal of the spleen q Have you ever attempted suicide? q Peptic Ulcer Disease q Have you had your thymus removed? q Do you have an artificial heart valve? q Other Do you have any other chronic medical conditions, conditions with a potential for relapse, or other conditions for which you are seen regularly by a medical professional? If so, what is the condition? Do you live with anyone or have close contact with a person/people living with one of the following conditions? HIV or AIDS Cancer Immune disorder Allergies: Do you have any medication allergies? If so, what is the medication? Are you allergic to any of the following compounds? q eggs q insect bites q sunlight sensitivity q thimerosal q penicillin q food q mercury q sulfa q other q vaccines q seafood Women only: Are you pregnant, suspect you are pregnant, or trying to become pregnant? Are you breastfeeding?
3 Date and dosage (if known) Booster doses Yellow Fever Cholera Measles Mumps Rubella MMR (Measles, Mumps, & Rubella) Tetanus Td TdAP DTP Polio (oral or injectable) Typhoid (oral or injectable) Hepatitis A Hepatitis B Hep A/B (twinrix) Rabies Plague Japanese Encephalitis Meningococcal Influenza Pneumococcal Varicella Haemophilus influenza B Tuberculin PPD test IMMUNIZATION HISTORY (Please list all previous vaccinations here) If at all possible, please bring a copy of your vaccination record with you on the day of your visit. Medications: Are you taking any medications? Medication Dosage Frequency (twice daily, etc.) Is there any other information you would like us to know regarding your travel plans or your medical history? Your signature implies that all necessary medical information has been provided to the best of your knowledge. Patient Signature: Date: / /
4 OFFICE USE ONLY Recommended Date Date Date Date Date Price* Declined Consult q 65 Yellow Fever Card q 6 Yellow Fever q 170 Cholera q N/A Measles q N/A Mumps q N/A Rubella q N/A MMR q 70 Tetanus q 25 Td q 25 TdAP q 95 Polio q 35 Typhoid q 60 Hepatitis A q 80 Hepatitis B q 70 Hep A/B q Rabies q TBD Plague q TBD JEV q TBD Meningococcal q 135 Influenza q 25 Pneumococcal q Pneumovax 115 Prevnar /230 Varicella q 155 PPD q 20 *Prices of vaccines are subject to change without prior notice * Administration Fee $20.00 for 1st vaccines, $10.00 for each one after that. Malaria: qprophylaxis rec Traveller's Diarrhea Topics: qno proph rec Traveller's diarrhea q CQ qwater # pills qbismuth subsalicylate (Pepto-Bismol) Malarone 2 tabs or 1 oz. Q 30 mins Insect protection q # pills up to 8 doses Mefloquine qloperamide # pills 4mg x 1 then 2mg after Traveler's Insurance q Doxycycline each loose stool <16mg/d # pills Primaquine qantibiotic Alcohol/drug use q # pills FQ # pills. q Cipro 500 bid q Bednets q Levoflox 500 qd Insomnia/jet lag q q Repellent Rifaximin q Ambien q Clothing q 200mg tid Macrolide Azithro 1gm x one Other:
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