PHYSICAL EXAM



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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:_________________________

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