PHYSICAL EXAM
[pic]
Date__________________
Welcome to ROCC, a center for your travel medicine needs. To make your journey as safe and enjoyable as possible, please provide the following information so we may help you with your needs.
What Countries do you plan to visit? Travel Dates?
______________________________ ______________ thru ___________
______________________________
______________________________ What is your occupation?
______________________________ _____________________________
What is the purpose of your visit? (Business, pleasure, mission, etc)
______________________________________________________________________________
What is modes of transportations LMP__________________
_____Air _____ Sea/Water Pregnant Y N
List any “adventure” activities you are planning (mountaineering, skydiving, SCBA):
______________________________________________________________________________
Please list any medical problems you may have here: __________________________________
______________________________________________________________________________
______________________________________________________________________________
Please list all medications you currently take:_________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please list any allergies to medications, foods, or other substances:________________________
______________________________________________________________________________
Please list any surgeries you’ve had and the approximate dates here:_______________________
______________________________________________________________________________
Please indicate any of these symptoms you have or recently had:
_____Weight loss _____Congestion _____Fever ______Chills _____Chest pain _____Visual changes _____Diarrhea ______Nausea _____Sore throat _____Abdominal pain _____Weakness ______Cough _____Joint pain _____Irreg. Heart beat _____Vomiting ______Rash
Please explain any of these symptoms or list any other symptoms:________________________
______________________________________________________________________________
Please indicate how much of the follow you do: Smoking_______ ___ Alcohol________
PLEASE SIGN HERE:_________________________________ DATE:__________________
PHYSICAL EXAM T______ BP________ P_______ R______O2 Sat______
Ht________ Wt_________
General: □ Awake, alert, NAD □ Other_____________________________
Head: □ NCAT □ Other_____________________________
Eyes: □ PERRl; EOMI □ Other_____________________________
Ears: □ TMs Clear bilaterally □ Other_____________________________
Nose: □ Mucosa Clear; No ST □ Other_____________________________
OP: □ Clear, moist, no exudate □ Other_____________________________
Neck: □ No LAD or thyromegaly □ Other_____________________________
CV: □ Heart nl S1S2; RRR: no m/r/g □ Other_____________________________
Chest: □ CTAB; No W/R/R □ Other_____________________________
Abd: □ Soft; BS+: NT/ND; no HSM □ Other_____________________________
Back: □ No midline or CVA tenderness □ Other_____________________________
Ext: □ No C/C/E □ Other_____________________________
PLAN
□ Food and Water Hygiene □ Circadian Rhythm/Sleep Aids_________
□ Water sanitation methods
□ Safe food practices □ Motion Sickness____________________
□ Handwashing
□ Traveler’s Diarrhea □ Altitude sickness____________________
□ Fluid rehydration □ Handouts Given:
□ Cipro 500 mg #______ □ MD Travel Health
□ Zithromax 250 mg #_______ □ Other
□ other____________________
MALARIA PROPHYLAXIS
□ DEET repellant 20-35% instructed.
□ Proper clothing wear
□ Permethrin to treat clothing
□ Avoidance techniques
□ Doxycycline 100mg #_______ One po QD 48 hrs prior/continue for 2 wks
□ Mefloquine 250mg #_______ One po q wk start 2 wks prior /continue 2-4 wks
□ Chloroquine 500mg #_______ One po q wk start 2 wks prior /continue 2-4 wks
□ Malarone #______ one po qd 48 hrs prior/1 wk after return
VACCINATIONS □ VIS given for vaccines administered
□ Routine childhood series UTD □ Rabies
□ Yellow Fever □ Japanese Encephalitis
□ Card complete □ Influenza
□ Typhoid □ Gardasil
□ Hepatitis A □ Other_______________________
□ Tetanus Booster □ Hepatits B Series
□ TDaP □ Twinrix
□ dT □ Polio
□ Meningococcus
Provider Signature:_________________________
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- nys school physical exam form
- ny state physical exam form
- nyc school physical exam form
- nys adult physical exam form
- school physical exam form florida
- free printable physical exam forms
- nys physical exam form
- adult physical exam form pdf
- nys child physical exam form
- hocm physical exam findings
- nyc physical exam form
- basic physical exam forms printable