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Pre-Travel

Age:  years old

Gender: 



HISTORY:

Presents for a pre-travel assessment

Destination: 

Duration of stay:  

Departure date: 

Return date: 

Purpose of travel: 

Planned activities: 

Health travel insurance: 



Vaccinations:

Hepatitis A: 

Hepatitis B: 

Typhoid: 

Yellow fever: 

Traveler's diarrhea: 

Japanese encephalitis: 

Rabies: 

Meningococcal: 

COVID-19: 





EXAM:

General appearance: , 

Vital signs: , BP , HR , RR , SpO2  %, Temp °





ASSESSMENT:

Pre-travel assessment





PLAN:

Investigations:

- Blood work: , 

Treatments:

- Vaccinations: , , , , , ,  if risk of animal bites, 

- Malaria prophylaxis: 

- Traveler's diarrhea: , , advice given on food and water precautions

- Motion sickness: 

- Altitude sickness: 

- Sun protection: , , advice given on sun avoidance and protective clothing

- Insect bite prevention: , , advice given on insect avoidance and protective clothing at night

Further care:

- Referral to travel medicine clinic

- Follow-up   post-travel

HISTORY: EXAM: ASSESSMENT: PLAN:

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