Travel Health Medical

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Traveler Information

Full Name	[Your Name]
Passport Number	123456789
Date of Birth:	January 1, 2050
Contact Information:	123-456-7890

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Travel Details

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

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

• Purpose of Travel: Vacation

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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

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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.

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Current Medications

List of Medications:

• Lisinopril, 10 mg, once daily

• Albuterol Inhaler, as needed

• Aspirin, 81 mg, once daily

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Vaccination Records

• Vaccinations Received:

  • Hepatitis A, 09/15/2056

  • Typhoid, 09/20/2056

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

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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.

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Emergency Contacts

• Primary Emergency Contact:

  • Name: Sarah J. Smith

  • Relationship: Spouse

  • Phone: (555) 987-6543

• Local Emergency Services Contact Information:

  • Thailand Emergency Number: 1669

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Healthcare Provider Information

• Name: Dr. Emily Johnson, MD

• Contact Information:

  • Phone: (555) 555-7890

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

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Date of Report: 10/01/2060

Signature:

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