Please fill out this form & bring it with you to your Travel Clinic Appointment and bring all current medication to your appointment. Alsobring 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
CURRICULUM VITAE DEBASISH KUILA PROFESSIONAL PREPARATION (Including postdoctoral training) : Northwestern University, Evanston, IL - Research Associate - 1988-1992 Los Alamos National Lab, Los Alamos, NM - Staff/Postdoctoral Fellow - 1985-1987 The University of Michigan, Ann Arbor, MI - Research Fellow - 1984-1985 The City University of New York, NY - Ph. D. in Inorganic (Phy. Org
Particle Size Analysis by Laser Diffraction Introduction 3. The scattering pattern at the detectors is the The underlying assumption in the design of laser sum of the individual scattering patterns diffraction instruments is that the scattered light pattern formed at the detector is a summation of the scattering pattern produced by each particle Experimental that is being sam