Health.gatech.edu
TRAVEL CLINIC
(Completed by Student)
STUDENT INFORMATION
DATE: _______________. GTID#: _____________________________
DOB: ______________
Email: _____________________________________________________________________________________________________
Name (Last, First, Middle)
Address:
City: ___________________________State: ______________ Country: _____________________Zip Code: _________________
TRAVEL INFORMATION (If you will travel to multiple areas, please compete for each destination)
DESTINATION
DEPARTURE DATE
RETURN DATE
TOTAL DAYS IN
DESTINATION
MEDICAL HISTORY (Check all that apply) Asthma
Breast Feeding
Other: _________________________________________________________________________________________
CURRENT MEDICATIONS (Include over the counter medications, vitamins, birth control)
___________________________
ALLERGIES
SHS Form_# 195_2010
TRAVEL CLINIC (Nurse Use Only)
Name: ________________________________
GTID#:___________________________Date: ______________
BP: ____________Temp: _________ Pulse: ________
Resp:__________
Allergies: ____________________________________________________________________________________________
Medications: _________________________________________________________________________________________
PREVIOUS VACCINATIONS
Date: ___________ Completed by: ____________________________________
RECOMMENDED VACCINATIONS
Follow protocol
PRESCRIPTIONS
INSTRUCTIONS Medication
Directions
One tablet per week. Start 1 week before departure,
continuing during travel and for 4 weeks after return on the
≤ 19 years 0.5 ml IM ≥ 20 years 1.0 ml
One tablet per week. Start 2 weeks before departure,
continuing during travel and for 8 weeks after return on the
Begin 1-2 days before, continuing during and 4 weeks
Measles, Mumps, Rubella (MMR-11®) (live)
One tablet PO qod. Complete series at least 3 days before
starting Mefloquine and avoid within 3 days of taking
antibiotics. Complete at least 1 week before departure.
Typhoid 21a (Vivotif Berna®) (Live)
1 bid for 3 days for distressing diarrhea. Seek medical care for bloody diarrhea or fever or non resolution in 5 days.
4 tablets as a single dose. Seek medical care if bloody
diarrhea or fever or diarrhea does not respond to
Initially 2 tablets, then one tablet after each loose stool.
Max of 16mg/day. Use to reduce the frequency and
volume of diarrhea. Do not use with fever or bloody
Date: ____________ Completed by: _____________________________________
TRAVEL INFORMATION DISCUSSED WITH PATIENT BY MD (Check all that apply)
CDC Geographical FAX sheet Finding a MD abroad Malaria Traveler’s Companion Traveler’s Diarrhea
Skin protection Others: ________________________________________________________
Source: http://health.gatech.edu/services/travel/Documents/195_Travel_Clinic.pdf
Revista Pediatría Electrónica Universidad de Chile Servicio Salud Metropolitano Norte Facultad de Medicina Hospital Clínico de Niños Departamento de Pediatría y Cirugía Infantil Roberto Del Río Actualización en RGE en pediatría Becaria APS 1º año Programa de Formación de Especialistas en Pediatría. Departamento de Pediatría y Cirugía Infantil. Campus Norte. Universidad d
Dances of Universal Peace, Kingston, Ontario presents a workshop with Yasmin Germaine Haut Senior Teacher of the Dances Saturday, October 20, 2007 Prior experience in dancing or singing is NOT required. The Dances of Universal Peace are an interfaith tradition of sacred dance and spiritual practice dedicated to peace, within and without. They integrate folk dance movem