Wesleyan University Davison Health Center
Travel Consultation
Name: ___________________________________ Age: ______ Phone: ________ Box# ______ Medical History (including splenectomy, Diabetes, Sickle Cel Disease, immune deficiency, immune
modulating drugs): ____________________________________________________________________ Current medications: __________________________________________________________________ Medication allergies (including vaccines, anti-malarials):_________________________________________ Wil you use/require contraception while abroad? Yes ___ No ___ Do you wish to take emergency contraception (Plan B) with you? _______ If your health insurance includes prescription coverage, please check with your insurer before your Health Center appointment to see whether or not your prescription plan includes travel vaccines (e.g., Rabies pre-exposure, Yel ow Fever) and malaria prophylaxis. Need for vaccines and malaria prophylaxis depends on your travel itinerary. Knowing in advance what kind of prescription coverage you have wil expedite your travel consult. Note: Wesleyan University’s insurance does not cover any vaccines or prescription medication. Itinerary (list countries and dates in anticipated order of travel) City, Country: _____________________________________ Dates: ___________________________
Type of travel/study (Please circle any that apply to you): Classroom-based study
Details, including ful name of program:______________________________________________
Type of accommodation (Please circle any that apply to you): Apartment
Details: _____________________________________________________________________________ Previous travel to developing areas: _______________________________________________________ Do you need a pre-travel physical exam and/or forms completed? Yes ____ No ____
(You wil need a separate appointment for this.)
Travel Vaccine History
Meningitis vaccine (Type?) Yel ow Fever
Vaccine Prices below subject to change – ask at front office Immunizations Required Required Recommended Recommended
Hepatitis A ($55/dose; 2 doses, lifetime)
Japanese Encephalitis (3 doses, 2 years)
Hepatitis B ($55/dose; 3 doses, lifetime?)
Inactive Polio Vaccine (IPV) ($35; lifetime)
Typhoid Oral Live vaccine (Vivotif)* Medication Directions
1 tablet weekly beginning 1-2 weeks before travel,
continuing during travel, and for 4 weeks after
leaving a malarious area. Take with food and 8 oz.
As for Chloroquine, but begin 2-3 weeks before
travel (assess tolerance, side effects).
1 tablet daily beginning 1-2 days before travel,
continuing during travel, and for 4 weeks after
leaving a malarious area. Take after meal with a full
glass of water. Use sunscreen with UVA/UVB
1 tablet daily beginning 1-2 days before travel,
continuing during travel, and for one week after
leaving a malarious area. Take with food or milky
Diarrhea Medication Directions
Packets of oral rehydration solution are available in
the pharmacies of most countries and can be mixed
with clean drinking water. A similar solution can be
made by adding 1/2 teaspoon of salt, 1/2 teaspoon
of baking soda, and 4 tablespoons of sugar to one
2 tablets initial y, then 1 tab after each unformed
1 tablet twice a day for 3 days for severe diarrhea
1 tablet daily for 3 days for severe diarrhea
High Altitude Medication Directions
1 tablet every 12 hours for 3 days, beginning day
before ascent, on the day of ascent, and on the
Do not use if Sulfa allergy! Q12h
If insomnia, may continue to take dose at bedtime
Jet Lag / Motion sickness /Other Medication Directions Discussed
Vaccine indications, side effects and contraindications
Importance of compliance with chemoprophylaxis.
Traveler’s diarrhea prevention and treatment (safe food and water)
Other insect-borne disease prevention and treatment
Sexually transmitted infection prevention
(Including obtaining supplies of regular or occasional medications)
Travel insurance/ Medical evacuation coverage
Post travel follow-up services including TB test 8-12 weeks after return.
Resources Supplied
CDC Health Information for International Travel URL
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Table 1: Food and Drug Interactions. Interactions/ Examples1 Guidelines ALLERGIES Antihistamine FOOD: Take without Fexofenadine/ALLEGRA. Fexofenadine/ALLEGRA Bioavailability decreases oratadine/CLARITIN juice. ALCOHOL: Avoid alcohol because it increases the sedative effects of the medications. ARTHRITIS FOOD: For rapid relief, moderate pain and take on emp
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