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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

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