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Travel Health Medical Report

Travel Health Medical

Traveler Information

Full Name

[Your Name]

Passport Number

123456789

Date of Birth:

January 1, 2050

Contact Information:

123-456-7890

Travel Details

  • Destination(s): Thailand (Bangkok, Phuket)

  • Travel Dates: 11/01/2055 to 11/15/2055

  • Purpose of Travel: Vacation

Medical History

Pre-existing Medical Conditions:

  • Hypertension: Diagnosed in 2054, managed with daily medication (Lisinopril 10 mg). Blood pressure is regularly monitored and remains within a controlled range.

  • Asthma: Mild, well-controlled with occasional use of an Albuterol inhaler, typically triggered by allergens and cold weather. The last asthma exacerbation occurred in March 2053, managed effectively with medication

    .

Previous Surgeries or Hospitalizations:

  • Appendectomy: Underwent a successful appendectomy on 05/10/2050 due to acute appendicitis. No complications during or after surgery. Fully recovered.

Allergies:

  • Penicillin: Severe allergic reaction, including rash and difficulty breathing. Alternative antibiotics should be used in case of bacterial infections.

  • Shellfish: Mild allergic reaction, including hives and gastrointestinal discomfort. Shellfish should be strictly avoided in meals.

Current Medications

List of Medications:

  • Lisinopril, 10 mg, once daily

  • Albuterol Inhaler, as needed

  • Aspirin, 81 mg, once daily

Vaccination Records

  • Vaccinations Received:

    • Hepatitis A, 09/15/2056

    • Typhoid, 09/20/2056

    • Tetanus-Diphtheria-Pertussis (Tdap), 08/10/2055

Health Risk Assessments

  1. Potential Health Risks for Destination:

    • Dengue Fever: High risk in urban areas during rainy season.

    • Zika Virus: Risk exists; recommend avoiding mosquito bites.

  2. Recommendations for Preventive Measures:

    • Take malaria prophylaxis (Doxycycline) starting one week before travel and continue for four weeks after returning.

    • Use insect repellent containing DEET when outdoors.

    • Stay in accommodations with air conditioning or window screens.

Emergency Contacts

  • Primary Emergency Contact:

    • Name: Sarah J. Smith

    • Relationship: Spouse

    • Phone: (555) 987-6543

  • Local Emergency Services Contact Information:

    • Thailand Emergency Number: 1669

Healthcare Provider Information

  • Name: Dr. Emily Johnson, MD

  • Contact Information:

    • Phone: (555) 555-7890

    • Address: 123 Health St, Wellness City, ST 12345

Date of Report: 10/01/2060


Signature:

Name of Healthcare Provider

[Your Company Name]

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