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Travel Intake Bradford

Traveller Questionnaire for Bradford or Aurora.

This form is to be completed prior to your travel medicine assessment.It helps focus on the main issues to be addressed in preparation for travel.


1.*Name?


2.*Address?


3.*Telephone Numbers ?


4.*Name and Address of Personal Physician?


5.*Do you want a copy post visit assessment sent to your physician?
yes
no


6.Your email address?


7.Date of appointment if known?


8.Do you wish to provided with an appointment time?
yes online
yes -call back
no- will call or email later


9.*Departure Date? Length of Trip? List all destinations to visit.


10.*Where do you plan to stay?
hotel
private home
budget accomodation
indigenous housing
backpacking
camping


11.*Modes of transportation
airplane
train
boat
car
bicycle


12.*Trip purpose and type?
business
pleasure
high altitude
trekking
scuba diving
rock climbing
hunting
fishing
missionary work
pilgrimage
river rafting


13.*With respect to previous travel have you had previous problems?


14.*What type of water purification do you plan to use?
filter
iodine
pristine
bottled


15.Do you plan to do the following?
plan to use a net?
Use permethrin?
Use Deet repellents?
Use antimalarials?
Carry backup antimalaria Rx?


16.If female please indicate LMP? Are you using contraception? Do you plan to become pregnant soon?


17.Have you lived or worked in a refugee camp?
yes
no


18.*Do you have any of the following problems?
depression
psychosis
diabetes
stomach ulcer
psoriasis
nil
asthma
high blood pressure
heart disease


19.Have you had prior problems travelling?
altitude sickness
malaria
travellers' diarrhea


20.*What medications are you currently taking?


21.*Do you have any allergies?


22.Are you in contact with persons with weakened immune systems, such as HIV or on chemotherapy
yes
no


23.*Have you purchased travel insurance or do you plan to?
yes
no


24.*Please list vaccines you have completed and you believe still provide protection for the length of trip. Please bring confirmatory proof of vaccination.
tetanus
diptheria
polio
MMR
Rabies
Japanese Encephalitis
Oral Cholera
Tb skin test
pneumovax
influenza
Typhoid oral
Typhoid injectable
Meningitis ACYW
Meningitis C only
Yellow Fever
Hepatitis A
Hepatitis B
Twinrix(Hep A&B)
Tick Borne Encephalitis
BCG
Adacel
Varivax-Chickenpox
Prevnar


25.Do you have any concerns about vaccinations?


26.Do you have any concern about any potential medications you may require, such as antimalarials?


27.Are you aware of the IAMAT organization?
yes
no


28.Would you like to be able to access your personal medical record overseas?
yes
no


29.Would you be interested in participating in a post travel health survey?
yes
no


30.Do you have some issues you need to have addressed


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