Medical History and Examination Form (DS‑1843)

Medical History and Examination Form (DS-1843) Patient Name: [Sarah Jenkins] Date of Birth: [15/03/1988] Age: [36 years old] Gender: [Female] Date of Examination: [01 November 2024] Reason for Travel: [Adventure tourism and volunteering] Destination(s): [Thailand, Vietnam, Cambodia, Laos] Departure Date: [01 January 2025] Return Date: [30 June 2025] Duration of Travel: [6 months] Previous Travel History: [Has travelled to Central America (Mexico, Costa Rica) in 2019 for a similar duration without significant health issues. Received standard vaccinations (Tetanus, Diphtheria, Polio, MMR) prior to that trip.] Medical History: Chronic Medical Conditions: [None reported.] Medications: [Oral contraceptive pill (Levlen ED) – takes daily as prescribed.] Allergies: [Penicillin (causes rash and itching), Dust mites (causes sneezing and watery eyes).] Immunisation Status (include dates if known): Tetanus/Diphtheria/Polio: [Last booster 2019] MMR: [2 doses, last dose childhood] Hepatitis A: [Completed course 2019] Hepatitis B: [Completed course 2019] Typhoid: [Last vaccination 2019] Yellow Fever: [Not previously vaccinated] Japanese Encephalitis: [Not previously vaccinated] Rabies: [Not previously vaccinated] Influenza: [Last vaccinated October 2024] Surgical History: [Appendectomy (2005) – no complications.] Hospitalisations: [None since appendectomy.] Family Medical History: [Mother has Type 2 Diabetes (diagnosed late 50s). Father has hypertension (managed with medication). No significant family history of infectious diseases relevant to travel.] Social History: Smoking: [Non-smoker] Alcohol: [Occasional social drinker (2-3 units per week)] Illicit Drugs: [Denies use] Sexual History: [Monogamous relationship, uses oral contraceptive for contraception.] Occupation: [Primary School Teacher] Recent Stressors: [None reported, excited about upcoming travel.] Review of Systems: General: [Denies fever, chills, weight changes, fatigue.] Skin: [No rashes, lesions, or itching.] Head, Eyes, Ears, Nose, Throat (HEENT): [No headaches, visual changes, hearing loss, sore throat. Occasional seasonal allergies (dust mites) well-controlled.] Cardiovascular: [No chest pain, palpitations, shortness of breath.] Respiratory: [No cough, wheezing, difficulty breathing.] Gastrointestinal: [No nausea, vomiting, diarrhoea, constipation, abdominal pain. Reports good appetite.] Genitourinary: [No dysuria, frequency, urgency, haematuria.] Musculoskeletal: [No joint pain, muscle aches, weakness.] Neurological: [No dizziness, syncope, numbness, tingling, seizures.] Psychiatric: [No anxiety, depression, mood changes. Reports generally good mental health.] Endocrine: [No polyuria, polydipsia, heat/cold intolerance.] Hematologic/Lymphatic: [No easy bruising, bleeding, swollen glands.] Physical Examination: General Appearance: [Well-nourished, alert, cooperative female in no acute distress.] Vital Signs: BP: [120/78 mmHg] HR: [72 bpm, regular] RR: [16 breaths/min] Temp: [36.8 °C] Oxygen Saturation: [98% on room air] HEENT: [Normocephalic, atraumatic. Conjunctivae clear, sclerae anicteric. Pupils equal, round, reactive to light and accommodation. Oropharynx clear. Tympanic membranes intact. Nasal mucosa clear.] Neck: [Supple, no lymphadenopathy, no thyromegaly.] Cardiovascular: [Normal S1, S2, no murmurs, rubs, or gallops. Peripheral pulses palpable and equal bilaterally.] Respiratory: [Lungs clear to auscultation bilaterally, no wheezes, rales, or rhonchi. Good air entry.] Abdomen: [Soft, non-tender, non-distended. Bowel sounds present in all four quadrants. No hepatosplenomegaly.] Musculoskeletal: [Full range of motion in all major joints, no tenderness or swelling. Normal gait.] Neurological: [Cranial nerves II-XII intact. Sensation intact to light touch. Deep tendon reflexes 2+ bilaterally. No focal neurological deficits.] Skin: [Warm, dry, intact. No rashes or lesions noted.] Assessment/Plan: Assessment: [36-year-old female planning 6-month adventure travel to Southeast Asia. Overall healthy with no significant chronic conditions or concerns beyond her penicillin allergy. Requires comprehensive pre-travel consultation to address destination-specific health risks and ensure up-to-date immunisations and prophylactic medications.] Plan: 1. (Discuss travel itinerary and specific risks for Thailand, Vietnam, Cambodia, Laos including food/water safety, insect-borne diseases, and potential for animal contact.) 2. (Review current vaccination status and recommend: - Hepatitis A (booster if indicated, though previous course completed) - Hepatitis B (booster if indicated, though previous course completed) - Typhoid (booster if indicated, though previous vaccination in 2019) - Japanese Encephalitis (primary course recommended due to rural travel and duration) - Rabies (pre-exposure prophylaxis recommended due to adventure travel and potential animal exposure) - Yellow Fever (not indicated for these destinations) - Measles/Mumps/Rubella (MMR) (ensure full 2 doses; consider booster if unsure of immunity) - Tetanus/Diphtheria/Pertussis (Tdap) (ensure up-to-date booster) - Polio (ensure up-to-date booster) - Influenza (already vaccinated for current season) 3. (Prescribe Malarone for malaria prophylaxis as indicated for specific regions within destinations, counsel on adherence and side effects.) 4. (Discuss mosquito bite prevention strategies including DEET/Picaridin repellents, permethrin-treated clothing, and bed nets.) 5. (Provide advice on food and water safety, including avoiding uncooked foods, tap water, and ice.) 6. (Discuss traveller's diarrhoea management, provide prescription for Ciprofloxacin and Loperamide.) 7. (Review general travel safety, including insurance, sun protection, and safe sex practices.) 8. (Educate on symptoms requiring medical attention during travel and post-travel.) 9. (Schedule follow-up appointment for vaccine administration and further counselling as needed.) 10. (Provide patient with relevant travel health information handouts.) Patient Consent: [Patient understands and agrees to the proposed vaccination schedule and travel health recommendations.] Signature of Clinician: "Dr. Thomas Kelly" Date: [01 November 2024]