The Number One Health Group – 2005 Returned Traveller History Sheet (RTHS)
Doctor:
Date form filled in:
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1. Client – Name and Address/ Contact Details |
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2. Date of Birth |
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3. Occupation |
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4. GP or Private doctor - Name and Address/ Contact Details Occupation |
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5. History of illness (date started/first
problems/any improvements/any deterioration/current state of physical health) |
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6. Past Medical History (include
diabetes/hypertension/past surgery) |
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7. Current medication (name of drug(s), when
first prescribed and what they are for |
Travel History:
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8. Where you born and raised in the UK (if
not where) |
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9. Have you worked/travelled in Africa – if
YES details re dates/duration/location/work undertaken |
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10. Have you worked/travelled in Asia – if YES details re
dates/duration/location/work undertaken |
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11. Have you worked/travelled in South or
Latin America – if YES details re
dates/duration/location/work undertaken |
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12. Have you worked/travelled in Australia/New
Zealand – if YES details re
dates/duration/location/work undertaken |
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13. Have you worked/travelled in the USA – if YES details re
dates/duration/location/work undertaken |
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14. Any other travel details |
Do you currently have
or have you had in the last 5 years any of the following symptoms or signs
(if YES give
dates/duration/severity):
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15. Diarrhoea (loose stools 3 times a day or
more) for more than 10 consecutive days |
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16. Bloody diarrhoea |
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17. Extreme Fatigue |
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18. Sweating at Night |
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19. Fever |
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20. Lymph Gland Enlargement
(neck/armpits/groin) |
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21. Skin rashes (other than eczema or
psoriasis) If YES were on body, what colour, does it itch, is it painful, is
it raised compared to the surrounding skin |
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22. Abnormal joint pains |
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23. Any other symptoms or signs (including
blood in urine, lumpy sperm, vaginal lumps) |
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24. Have you any family members who have had
similar symptoms or signs |
Have you seen any of
the following about your illness and what investigations did they do and
what were their
thoughts as to an explanation for the illness:
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Person seen |
Tick if YES |
Investigations done |
Explanation of
illness (if none write NONE) |
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25. General Practitioner |
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26. Neurologist (Nerves) |
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27. Rheumatologist (Joints) |
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28. Gastroenterologist (Bowels) |
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29. Psychiatrist or Psychologist |
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30. Dermatologist (Skin) |
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31. Alternative Practitioner |
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32. Other include details |
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In the last 10 years
have you had any of the following vaccines?
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Vaccine |
No (Tick) |
Yes (Tick) and give
date or year |
Not Sure(Tick) |
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33. Tetanus |
If No have you had 5 previous tetanus
injections? |
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34. Polio |
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35. Hepatitis A first course or booster |
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If Yes and primary
course did you have 2 doses within a year of each other? Y/N Booster Y/N |
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36. Hepatitis B first course or booster |
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If Yes and primary
course did you have 3 doses within a year of each other? Y/N Booster Y/N |
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37. Diphtheria |
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38. Yellow Fever |
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39. Other |
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In the last 3-5 years
have you had any of the following vaccines?
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Vaccine |
No (Tick) |
Yes (Tick) and give
date or year |
Not Sure(Tick) |
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40. Typhoid |
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41. Meningitis |
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Was it: Hib Y/N Men C Y/N Men A and C Y/N Men ACWY Y/N |
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42. Rabies |
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Intradermal
(skin) Y/N Intramuscular Y/N |
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43. Tick Borne Encephalitis |
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44. Japanese Encephalitis |
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45. Other |
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46. Other |
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What do you think might
be the cause of your illness and what are your reasons for this view
Have any of the
following tests been done and what were the results
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TEST |
Tick if Normal and
write NS if Not Sure |
IF ABNORMAL give
details |
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47. Full Blood Count |
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48. Urea and electrolytes |
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49. Liver Function |
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50. Stool test |
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51. X-Ray |
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52. Ultrasound |
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53. Investigative Surgery |
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54. Investigative Procedure |
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55. Other (give details) |
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