Travel Visit Questionnaire

The Travel Visit Questionnaire is to be filled out by family as an online form before the appointment. It will be sent to GPAM physicians via email so research on your travel area can be done ahead of time.  Appointments to review your travel situation should be made at least 4 weeks before you plan to leave the country.  We will give you information regarding your destination, and we will give you prescriptions for the medications we do not carry in the office.

Please Scroll down for Online Form:

Patient Name:
Date of Birth:
Phone Number:
When are you leaving?
What country and city are you traveling to?
How long will you be traveling?
Will you be in more urban (city) or rural areas?
Have you ever had difficulties or side effects with malaria medications before?
Is there a family history of G6PD deficiency?
Have you had yellow fever or typhoid vaccine in the past?
Has your child been tested for tuberculosis? (TB) Or had a recent PPD?
If so, when, and where:
Do you need any medication refills for your trip?
If so, please name the medication(s):
Do you have any other questions for the doctor today?

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