travMECK
Dear Traveler:
Thank you for choosing travMECK (Mecklenburg County Health Department Travel Clinic) for
your travel health care needs. Our travel services are available to all residents 16 years of age and
older. We want to assist you in anyway possible to ensure that you have a safe and healthy travel
experience. Our goal is to provide you with the most cost-effective, up to date treatment and
latest travel information available prior to your departure.
As your travel health care providers we are apprised of the travel advisories from the World
Health Organization (www.who.int/en/), The CDC (www.cdc.gov/travel), the U.S. State
Department website: www.state.gov/travel and the Travax Software Program. The travel
information we gather is specialized to meet your individual needs based on your medical history
and current medical status in relation to your proposed trip itinerary.
Even with receiving education, vaccines, and medications, travelers are not 100 percent
protected against all diseases. There are no preventive measures that are 100 percent effective.
Therefore, it is wise to follow safe food and water precautions, good hand washing along with
protection from insects especially mosquitoes. This will increase your ability to prevent many
common illnesses that traveler’s abroad experience.
Enclosed is the Travel Clinic Questionnaire; please complete in its entirety and return along with
an official copy of your shot record no later than 1 week (7 days) prior to your appointment.
Appointments will be cancelled if questionnaire is not received by deadline:
1. Fax: (704) 432-0508 and mark - Attention: travMECK
2. Drop off or mail to us at: 249 Billingsley Rd, Charlotte NC 28211- Attn: travMECK
There will be consultation, vaccine and administration fees associated with your visit.
Medicaid, Medicare, North Carolina Health choice and private insurance carriers will be
contacted prior to your visit for travel service pre-authorization (thus, information must be
completed in its entirety). For uncovered services, payment is due at the time of service by
Cash, Check, Credit Card (Discover, MasterCard, and Visa) and Flexible Spending
Accounts with a Credit Card logo.
For questions or concerns please contact our travel health professionals at 704-432-TRIP.
Safe travels to you,
Lena K. White, M.D., M Ed
MECKLENBURG COUNTY HEALTH DEPARTMENT
Travel Clinic Questionnaire
Fill in all blanks and return 1 week (7 days) prior to appointment. Appointments will be cancelled if
information is not received by deadline.
APPOINTMENT DATE: ________________________
Name_____________________________________________
DOB
Address____________________________________________
Phone #
Email Address________________________________
_______________________
_______________________
Best Time to Contact For Questions ___________
□am □pm
PLEASE NOTE: Medications are prescribed based on travel itinerary and length of stay in certain regions.
Following your exact itinerary, please state below the date of arrival in each country and date of departure
from each country/region.
Date of Departure from USA__________________
Return Date to USA________________________
Destination (City and Country)
Arrival
Date
Type of Area
Departure
Date
1. _______________________
____________
___________
□ Urban □Rural
2.________________________
____________
___________
□ Urban □Rural
3.________________________
____________
___________
□ Urban □Rural
Purpose of visit (student, mission, vacation etc):__________________________________________________
Will you be staying in a hotel, home, campsite or tent? ____________________________________________
Will your destination be to a HIGH ALTITUDE (above 8,000 feet) area?
□Yes □ No
If yes, then how many days will you be at high elevation? __________________________________
HAVE YOU EVER RECEIVED ANY OF THE FOLLOWING VACCINES? If so, indicate date (month, day, and
year). Please attach a copy of official shot required when questionnaire is turned in.
Hepatitis A ___________ Hepatitis B ___________
Cholera
____________
Influenza ____________
Other__________________
Typhoid
___________
Meningitis ___________
Yellow Fever __________ Polio Booster __________ Tetanus/Diphtheria _________
Rabies _____________
Varicella __________
BCG_____________
NAME____________________________________
Have you ever had hepatitis, malaria or any kind of travel-related illness? □Yes (please explain) □ No
____________________________________________________________________________________
Have you ever had a reaction to a vaccine? □Yes (if yes, describe reaction) □ No
____________________________________________________________________________________
Are you allergic to anything (food, medicine, bug bites, etc.)? □Yes (if yes, describe reaction) □ No
_________________________________________________________________________________________
Has a doctor given you any vaccines or medications for this trip? □ Yes (if yes, then list below) □ No
__________________________________________________________________________________________
LIST ANY PRESCRIPTION OR NON-PRESCRIPTION MEDS YOU TAKE (including vitamins, herbs etc):
__________________________________________________________________________________________
List any immune system problems:
___________________________________________________________________________________________
List any medical conditions surgeries or hospitalizations and dates (including any problems with the thymus gland
i.e. thymus gland removal, myasthenia gravis, DiGeorge syndrome or thymoma):
_____________________________________________________________________________________________
Females: Last Menstrual Period (LMP) _______________
Are you currently pregnant? □Yes □ No
Are you breastfeeding? □Yes □ No
Do you have travel medical insurance? □ Yes □ No
Pharmacy Name: ______________
_____________________
Primary Care Physician
Phone Number: _______________
___________________
Location
____________________
Phone Number
There will be consultation, vaccine and administration fees associated with your visit. Medicaid, Medicare,
North Carolina Health choice and private insurance carriers will be contacted prior to your visit for travel
service pre-authorization. For uncovered services, payment is due at the time of service by Cash, Check,
Credit Card (American Express, Discover, MasterCard, and Visa) and Flexible Spending Accounts with a
Credit Card logo.
Client Signature_______________________________
Date_____________________
Reviewed by travMECK RN_____________________
Date______________________
Reviewed by travMECK MD_____________________
Date________________________
Revised 6/10/14 ls/jfw