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Protocol - International Travel History

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Protocol Name from Source:

The Expert Review Panel has not reviewed this measure yet.

Availability:

Publicly available

Description:

From the Global Surveillance Network of the International Society of Travel Medicine (ISTM) and the Centers for Disease Control and Prevention (CDC), The GeoSentinel protocol is a self-reported questionnaire that collects information on a respondent's recent (within the last 6 months) and previous (within the last 5 years) travel history. It also provides a template for the clinician to use in assessing the exposure details.

Protocol:

1. General Information

Gender
[ ] Male
[ ] Female

Age

*Today's Date Month/Day/Year
(Clinic Visit Date)

*Country of Birth

Primary Country of Residency Before Age 10

*Country of Citizenship

*Country of Current Residence

[ ] Immigrant

If you were not born in USA, indicate as Month/Day/Year
closely as possible the date
you first arrived here:



2. History of Recent Travel

List in order, starting with the most recent trip, all international travel in the past 6 months. Using 1 line for each separate trip, list each country visited during that trip. Indicate if the trip included travel on a ship.

Trip

*Trip Start Date
Month/Day/Year

*Trip End Date
Month/Day/Year

*Country 1

*Country 2

*Country 3

*Country 4

*Country 5

1

             

2

             

3

             

4

             

5

             

6

             


3. History of Previous Travel

List all countries visited or resided in over the past 5 years (exclude country of current residence and travel in the past 6 months listed above). 1. List each country only once. 2. CHECK the year(s) of travel to that country. 3. CHECK the box below the year if any stay in that country in that year was longer than 30 consecutive days.

*Country:

1

2

3

*Check each year of travel to the country

[ ]
2009

[ ]
2008

[ ]
2007

[ ]
2006

[ ]
2005

[ ]
2004

[ ]
2009

[ ]
2008

[ ]
2007

[ ]
2006

[ ]
2005

[ ]
2004

[ ]
2009

[ ]
2008

[ ]
2007

[ ]
2006

[ ]
2005

[ ]
2004

Check if stay was >30 consecutive days

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

*Country:

4

5

6

*Check each year of travel to the country

[ ]
2009

[ ]
2008

[ ]
2007

[ ]
2006

[ ]
2005

[ ]
2004

[ ]
2009

[ ]
2008

[ ]
2007

[ ]
2006

[ ]
2005

[ ]
2004

[ ]
2009

[ ]
2008

[ ]
2007

[ ]
2006

[ ]
2005

[ ]
2004

Check if stay was >30 consecutive days

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

[ ]

PATIENT SHOULD NOT COMPLETE THIS PAGE—TO BE COMPLETED BY CLINICIAN ONLY

Country of Exposure >5 years ago: If a country of exposure that is related to a Final Diagnosis for the current illness was visited more than 5 years ago, add that country to the history of previous travel (section 3) and indicate that travel there occurred >5 years ago (use the notation <2003).

4. Exposure Details

*Country of Exposure/Other (Check the applicable box and/or enter up to 2 countries. The country[s] where the current illness as defined by the final diagnosis was to a high degree of certainty acquired. A single country of exposure is the preferred standard. However, 2 countries may be designated if the likelihood of exposure is almost equal amongst the 2 countries. Exposure Country Not Ascertainable should be selected for situations where it is not possible to attribute Country of Exposure.):

[ ] Exposure Country Not Ascertainable [ ] Ship [ ] Plane

Country
1: _____________________________ Country
2: ____________________________

More Specific Place of Exposure (below level of country; i.e., city, state, location, event; leave blank if 2 countries are listed above):

*Reason for Travel Related to Current Illness (Check One):

[ ] Tourism

[ ] Business

[ ] Missionary/Volunteer/

Researcher/Aid Work

[ ] Student

[ ] Medical Tourism

[ ] Immigration

[ ] Visiting Friends & Relatives

[ ] Military

Risk Level Qualifier (Check One): [ ] Pre-Arranged or Organized Travel [ ] Risk Travel
                                                   [ ] Expatriate

*Clinical Setting (Check One): [ ] Seen During Travel [ ] Seen After Travel
                                              [ ] Immigration Travel Only

*Patient Type(Check One): [ ] Inpatient [ ] Outpatient [ ] TeleConsult-Outpatient
                                         [ ] TeleConsult-Inpatient

Did the patient have a pre-travel encounter with a health care provider? (Check One):
[ ] Yes [ ] No [ ] Don't Know

*Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply):

[ ] Abnormal Lab Test

[ ] Asymptomatic Screening

[ ] Cardiac

[ ] Fatigue

[ ] Fever

[ ] Gastrointestinal

[ ] Genitourinary

[ ] HEENT

[ ] Lymphatic

[ ] Musculoskeletal

[ ] Neurologic

[ ] Psychologic

[ ] Respiratory

[ ] Skin

[ ] Other If "Other," Specify: ____________________________________________________

5. Diagnoses

Dx#

Working Diagnosis

Working Dx Status (circle one)

*Final Diagnosis

*Final Dx Status (circle one)

1

 

C P S E CT PT ST

 

C P S

2

 

C P S E CT PT ST

 

C P S

3

 

C P S E CT PT ST

 

C P S

4

 

C P S E CT PT ST

 

C P S

5

 

C P S E CT PT ST

 

C P S

Dx Status Legend: C = Confirmed; P = Probable; S = Suspected; E = Exclusion of;
CT, PT, ST = Status Post (Confirmed, Probable, Suspected)

[ ] Not Travel Related Check this box if patient was primarily diagnosed with an infection or disease that was acquired or existed at home prior to departure or which was acquired after travel but prior to the clinic visit. If Not Travel Related is checked, Main Presenting Symptoms are still required; however, all other fields in the Exposure Details section are optional, but they should be answered as related to the reason for clinic visit and not related to the current illness.

Dx Diagnosis
* = These items are required fields for successful online data entry. Note: Sections 2 and 3 may be omitted if not applicable.

Personnel and Training Required

A health professional to diagnose diseases and conditions is required to complete Sections┬┐4 and 5 of the questionnaire.

Equipment Needs

Either a paper-and-pencil or computer-assisted instrument may be used. If a computer-assisted instrument is used, computer software may be necessary to develop the instrument.

Requirements

Requirement CategoryRequired
Average time of greater than 15 minutes in an unaffected individualNo
Major equipmentNo
Specialized requirements for biospecimen collectionNo
Specialized trainingYes

Mode of Administration

Self-administered

Life Stage:

Adult

Specific Instructions:

Updates to the date ranges within the protocol will need to be made to collect accurate data based on the start date of future studies.

For Sections 2 and 3, if the respondent has more travel information than the allotted space allows, please collect that information as well.

Research Domain Information

Release Date:

November 12, 2010

Definition

This measure is a questionnaire to collect data on a respondent's international travel in the past 6 months and the last 5 years and a clinical assessment of the exposure details.

Purpose

This measure can be used to gather information on a respondent's international travel for a clinician to identify the source of potential health exposures.

Selection Rationale

The GeoSentinel questionnaire was selected because it is recognized as a worldwide system for communication and collection of data on morbidity due to travel-related infection. It includes a protocol based on available current research that is valid and reliable and that is associated with disease outcomes.

Language

English

Standards

StandardNameIDSource
Common Data Elements (CDE)International Travel History Assessment Description Text3151204CDE Browser
Logical Observation Identifiers Names and Codes (LOINC)International travel hx proto62888-3LOINC

Process and Review

The Expert Review Panel has not reviewed this measure yet.

Source

International Society of Travel Medicine (ISTM) and the Centers for Disease Control and Prevention (CDC). 2008 GeoSentinel Questionnaire. Sections 1–5.

General References

None

Protocol ID:

161201

Variables:

Export Variables
Variable NameVariable IDVariable DescriptionVersiondbGaP Mapping
PX161201_GenderPX161201010000Gender4N/A
PX161201_AgePX161201020000Age4N/A
PX161201_Date_MonthPX161201030100Today's Date (Clinic Visit Date) - Day4N/A
PX161201_Date_DayPX161201030200Today's Date (Clinic Visit Date) - Month4N/A
PX161201_Date_YearPX161201030300Today's Date (Clinic Visit Date) - Year4N/A
PX161201_Country_Of_BirthPX161201040000Country of Birth4N/A
PX161201_Primary_Country _Before _10PX161201050000Primary Country of Residency Before Age 104N/A
PX161201_Country_Of_CitizenshipPX161201060000Country of Citizenship4N/A
PX161201_Country_Of_Current_ResidencePX161201070000Country of Current Residence4N/A
PX161201_ImmigrantPX161201080000Immigrant4N/A
PX161201_Date_Arrived_US_MonthPX161201090100If you were not born in USA, indicate as closely as possible the date you first arrived here: Enter Month4N/A
PX161201_Date_Arrived_US_DayPX161201090200If you were not born in USA, indicate as closely as possible the date you first arrived here: Enter Day4N/A
PX161201_Date_Arrived_US_YearPX161201090300If you were not born in USA, indicate as closely as possible the date you first arrived here: Enter Year4N/A
PX161201_Recent_Travel_Trip1_Country_5PX161201100000History of Recent Travel - Trip 1 - Country 54N/A
PX161201_Recent_Travel_Trip1_Start_MonthPX161201100100History of Recent Travel - Trip 1 Start Date - Month4N/A
PX161201_Recent_Travel_Trip1_Start_DayPX161201100200History of Recent Travel - Trip 1 Start Date - Day4N/A
PX161201_Recent_Travel_Trip1_Start_YearPX161201100300History of Recent Travel - Trip 1 Start Date - Year4N/A
PX161201_Recent_Travel_Trip1_End_MonthPX161201100400History of Recent Travel - Trip 1 End Date - Month4N/A
PX161201_Recent_Travel_Trip1_End_DayPX161201100500History of Recent Travel - Trip 1 End Date - Day4N/A
PX161201_Recent_Travel_Trip1_End_YearPX161201100600History of Recent Travel - Trip 1 End Date - Year4N/A
PX161201_Recent_Travel_Trip1_Country_1PX161201100700History of Recent Travel - Trip 1 - Country 14N/A
PX161201_Recent_Travel_Trip1_Country_2PX161201100800History of Recent Travel - Trip 1 - Country 24N/A
PX161201_Recent_Travel_Trip1_Country_3PX161201100900History of Recent Travel - Trip 1 - Country 34N/A
PX161201_Recent_Travel_Trip1_Country_4PX161201101000History of Recent Travel - Trip 1 - Country 44N/A
PX161201_Recent_Travel_Trip2_Country_5PX161201110000History of Recent Travel - Trip 2 - Country 54N/A
PX161201_Recent_Travel_Trip2_Start_MonthPX161201110100History of Recent Travel - Trip 2 Start Date - Month4N/A
PX161201_Recent_Travel_Trip2_Start_DayPX161201110200History of Recent Travel - Trip 2 Start Date - Day4N/A
PX161201_Recent_Travel_Trip2_Start_YearPX161201110300History of Recent Travel - Trip 2 Start Date - Year4N/A
PX161201_Recent_Travel_Trip2_End_MonthPX161201110400History of Recent Travel - Trip 2 End Date - Month4N/A
PX161201_Recent_Travel_Trip2_End_DayPX161201110500History of Recent Travel - Trip 2 End Date - Day4N/A
PX161201_Recent_Travel_Trip2_End_YearPX161201110600History of Recent Travel - Trip 2 End Date - Year4N/A
PX161201_Recent_Travel_Trip2_Country_1PX161201110700History of Recent Travel - Trip 2 - Country 14N/A
PX161201_Recent_Travel_Trip2_Country_2PX161201110800History of Recent Travel - Trip 2 - Country 24N/A
PX161201_Recent_Travel_Trip2_Country_3PX161201110900History of Recent Travel - Trip 2 - Country 34N/A
PX161201_Recent_Travel_Trip2_Country_4PX161201111000History of Recent Travel - Trip 2 - Country 44N/A
PX161201_Recent_Travel_Trip3_Country_5PX161201120000History of Recent Travel - Trip 3 - Country 54N/A
PX161201_Recent_Travel_Trip3_Start_MonthPX161201120100History of Recent Travel - Trip 3 Start Date - Month4N/A
PX161201_Recent_Travel_Trip3_Start_DayPX161201120200History of Recent Travel - Trip 3 Start Date - Day4N/A
PX161201_Recent_Travel_Trip3_Start_YearPX161201120300History of Recent Travel - Trip 3 Start Date - Year4N/A
PX161201_Recent_Travel_Trip3_End_MonthPX161201120400History of Recent Travel - Trip 3 End Date - Month4N/A
PX161201_Recent_Travel_Trip3_End_DayPX161201120500History of Recent Travel - Trip 3 End Date - Day4N/A
PX161201_Recent_Travel_Trip3_End_YearPX161201120600History of Recent Travel - Trip 3 End Date - Year4N/A
PX161201_Recent_Travel_Trip3_Country_1PX161201120700History of Recent Travel - Trip 3 - Country 14N/A
PX161201_Recent_Travel_Trip3_Country_2PX161201120800History of Recent Travel - Trip 3 - Country 24N/A
PX161201_Recent_Travel_Trip3_Country_3PX161201120900History of Recent Travel - Trip 3 - Country 34N/A
PX161201_Recent_Travel_Trip3_Country_4PX161201121000History of Recent Travel - Trip 3 - Country 44N/A
PX161201_Recent_Travel_Trip4_Country_5PX161201130000History of Recent Travel - Trip 4 - Country 54N/A
PX161201_Recent_Travel_Trip4_Start_MonthPX161201130100History of Recent Travel - Trip 4 Start Date - Month4N/A
PX161201_Recent_Travel_Trip4_Start_DayPX161201130200History of Recent Travel - Trip 4 Start Date - Day4N/A
PX161201_Recent_Travel_Trip4_Start_YearPX161201130300History of Recent Travel - Trip 4 Start Date - Year4N/A
PX161201_Recent_Travel_Trip4_End_MonthPX161201130400History of Recent Travel - Trip 4 End Date - Month4N/A
PX161201_Recent_Travel_Trip4_End_DayPX161201130500History of Recent Travel - Trip 4 End Date - Day4N/A
PX161201_Recent_Travel_Trip4_End_YearPX161201130600History of Recent Travel - Trip 4 End Date - Year4N/A
PX161201_Recent_Travel_Trip4_Country_1PX161201130700History of Recent Travel - Trip 4 - Country 14N/A
PX161201_Recent_Travel_Trip4_Country_2PX161201130800History of Recent Travel - Trip 4 - Country 24N/A
PX161201_Recent_Travel_Trip4_Country_3PX161201130900History of Recent Travel - Trip 4 - Country 34N/A
PX161201_Recent_Travel_Trip4_Country_4PX161201131000History of Recent Travel - Trip 4 - Country 44N/A
PX161201_Recent_Travel_Trip5_Country_5PX161201140000History of Recent Travel - Trip 5 - Country 54N/A
PX161201_Recent_Travel_Trip5_Start_MonthPX161201140100History of Recent Travel - Trip 5 Start Date - Month4N/A
PX161201_Recent_Travel_Trip5_Start_DayPX161201140200History of Recent Travel - Trip 5 Start Date - Day4N/A
PX161201_Recent_Travel_Trip5_Start_YearPX161201140300History of Recent Travel - Trip 5 Start Date - Year4N/A
PX161201_Recent_Travel_Trip5_End_MonthPX161201140400History of Recent Travel - Trip 5 End Date - Month4N/A
PX161201_Recent_Travel_Trip5_End_DayPX161201140500History of Recent Travel - Trip 5 End Date - Day4N/A
PX161201_Recent_Travel_Trip5_End_YearPX161201140600History of Recent Travel - Trip 5 End Date - Year4N/A
PX161201_Recent_Travel_Trip5_Country_1PX161201140700History of Recent Travel - Trip 5 - Country 14N/A
PX161201_Recent_Travel_Trip5_Country_2PX161201140800History of Recent Travel - Trip 5 - Country 24N/A
PX161201_Recent_Travel_Trip5_Country_3PX161201140900History of Recent Travel - Trip 5 - Country 34N/A
PX161201_Recent_Travel_Trip5_Country_4PX161201141000History of Recent Travel - Trip 5 - Country 44N/A
PX161201_Recent_Travel_Trip6_Country_5PX161201150000History of Recent Travel - Trip 6 - Country 54N/A
PX161201_Recent_Travel_Trip6_Start_MonthPX161201150100History of Recent Travel - Trip 6 Start Date - Month4N/A
PX161201_Recent_Travel_Trip6_Start_DayPX161201150200History of Recent Travel - Trip 6 Start Date - Day4N/A
PX161201_Recent_Travel_Trip6_Start_YearPX161201150300History of Recent Travel - Trip 6 Start Date - Year4N/A
PX161201_Recent_Travel_Trip6_End_MonthPX161201150400History of Recent Travel - Trip 6 End Date - Month4N/A
PX161201_Recent_Travel_Trip6_End_DayPX161201150500History of Recent Travel - Trip 6 End Date - Day4N/A
PX161201_Recent_Travel_Trip6_End_YearPX161201150600History of Recent Travel - Trip 6 End Date - Year4N/A
PX161201_Recent_Travel_Trip6_Country_1PX161201150700History of Recent Travel - Trip 6 - Country 14N/A
PX161201_Recent_Travel_Trip6_Country_2PX161201150800History of Recent Travel - Trip 6 - Country 24N/A
PX161201_Recent_Travel_Trip6_Country_4PX161201151000History of Recent Travel - Trip 6 - Country 44N/A
PX161201_Previous_Travel_Country1PX161201160100History of Previous Travel - Country 14N/A
PX161201_Previous_Travel_Country1_ThisYearPX161201160201History of Previous Travel - Country 1 - Check if travelled to country this year.4N/A
PX161201_Previous_Travel_Country1_LastYearPX161201160202History of Previous Travel - Country 1 - Check if travelled to country last year.4N/A
PX161201_Previous_Travel_Country1_TwoYearsAgoPX161201160203History of Previous Travel - Country 1 - Check if travelled to country two years ago.4N/A
PX161201_Previous_Travel_Country1_ThreeYearsAgoPX161201160204History of Previous Travel - Country 1 - Check if travelled to country three years ago.4N/A
PX161201_Previous_Travel_Country1_FourYearsAgoPX161201160205History of Previous Travel - Country 1 - Check if travelled to country four years ago.4N/A
PX161201_Previous_Travel_Country1_FiveYearsAgoPX161201160206History of Previous Travel - Country 1 - Check if travelled to country five years ago.4N/A
PX161201_Previous_Travel_Country1_30daysThisYearPX161201160300History of Previous Travel - Country 1 - Stay was longer than 30 consecutive days this year4N/A
PX161201_Previous_Travel_Country1_30daysLastYearPX161201160400History of Previous Travel - Country 1 - Stay was longer than 30 consecutive days last year4N/A
PX161201_Previous_Travel_Country1_30daysTwoYearsAgoPX161201160500History of Previous Travel - Country 1 - Stay was longer than 30 consecutive days two years ago4N/A
PX161201_Previous_Travel_Country1_30daysThreeYearsAgoPX161201160600History of Previous Travel - Country 1 - Stay was longer than 30 consecutive days three years ago4N/A
PX161201_Previous_Travel_Country1_30daysFourYearsAgoPX161201160700History of Previous Travel - Country 1 - Stay was longer than 30 consecutive days four years ago4N/A
PX161201_Previous_Travel_Country1_30daysFiveYearsAgoPX161201160800History of Previous Travel - Country 1 - Stay was longer than 30 consecutive days five years ago4N/A
PX161201_Previous_Travel_Country2PX161201170100History of Previous Travel - Country 24N/A
PX161201_Previous_Travel_Country2_ThisYearPX161201170201History of Previous Travel - Country 2 - Check if travelled to country this year.4N/A
PX161201_Previous_Travel_Country2_LastYearPX161201170202History of Previous Travel - Country 2 - Check if travelled to country last year.4N/A
PX161201_Previous_Travel_Country2_TwoYearsAgoPX161201170203History of Previous Travel - Country 2 - Check if travelled to country two years ago.4N/A
PX161201_Previous_Travel_Country2_ThreeYearsAgoPX161201170204History of Previous Travel - Country 2 - Check if travelled to country three years ago.4N/A
PX161201_Previous_Travel_Country2_FourYearsAgoPX161201170205History of Previous Travel - Country 2 - Check if travelled to country four years ago.4N/A
PX161201_Previous_Travel_Country2_FiveYearsAgoPX161201170206History of Previous Travel - Country 2 - Check if travelled to country five years ago.4N/A
PX161201_Recent_Travel_Trip6_Country_3PX161201150900History of Recent Travel - Trip 6 - Country 34N/A
PX161201_Previous_Travel_Country2_30daysThisYearPX161201170300History of Previous Travel - Country 2 - Stay was longer than 30 consecutive days this year4N/A
PX161201_Previous_Travel_Country2_30daysLastYearPX161201170400History of Previous Travel - Country 2 - Stay was longer than 30 consecutive days last year4N/A
PX161201_Previous_Travel_Country2_30daysTwoYearsAgoPX161201170500History of Previous Travel - Country 2 - Stay was longer than 30 consecutive days two years ago4N/A
PX161201_Previous_Travel_Country2_30daysThreeYearsAgoPX161201170600History of Previous Travel - Country 2 - Stay was longer than 30 consecutive days three years ago4N/A
PX161201_Previous_Travel_Country2_30daysFourYearsAgoPX161201170700History of Previous Travel - Country 2 - Stay was longer than 30 consecutive days four years ago4N/A
PX161201_Previous_Travel_Country2_30daysFiveYearsAgoPX161201170800History of Previous Travel - Country 2 - Stay was longer than 30 consecutive days five years ago4N/A
PX161201_Previous_Travel_Country3PX161201180100History of Previous Travel - Country 34N/A
PX161201_Previous_Travel_Country3_ThisYearPX161201180201History of Previous Travel - Country 3 - Check if travelled to country this year.4N/A
PX161201_Previous_Travel_Country3_LastYearPX161201180202History of Previous Travel - Country 3 - Check if travelled to country last year.4N/A
PX161201_Previous_Travel_Country3_TwoYearsAgoPX161201180203History of Previous Travel - Country 3 - Check if travelled to country two years ago.4N/A
PX161201_Previous_Travel_Country3_ThreeYearsAgoPX161201180204History of Previous Travel - Country 3 - Check if travelled to country three years ago.4N/A
PX161201_Previous_Travel_Country3_FourYearsAgoPX161201180205History of Previous Travel - Country 3 - Check if travelled to country four years ago.4N/A
PX161201_Previous_Travel_Country3_FiveYearsAgoPX161201180206History of Previous Travel - Country 3 - Check if travelled to country five years ago.4N/A
PX161201_Previous_Travel_Country3_30daysThisYearPX161201180300History of Previous Travel - Country 3 - Stay was longer than 30 consecutive days this year4N/A
PX161201_Previous_Travel_Country3_30daysLastYearPX161201180400History of Previous Travel - Country 3 - Stay was longer than 30 consecutive days last year4N/A
PX161201_Previous_Travel_Country3_30daysTwoYearsAgoPX161201180500History of Previous Travel - Country 3 - Stay was longer than 30 consecutive days two years ago4N/A
PX161201_Previous_Travel_Country3_30daysThreeYearsAgoPX161201180600History of Previous Travel - Country 3 - Stay was longer than 30 consecutive days three years ago4N/A
PX161201_Previous_Travel_Country3_30daysFourYearsAgoPX161201180700History of Previous Travel - Country 3 - Stay was longer than 30 consecutive days four years ago4N/A
PX161201_Previous_Travel_Country3_30daysFiveYearsAgoPX161201180800History of Previous Travel - Country 3 - Stay was longer than 30 consecutive days five years ago4N/A
PX161201_Previous_Travel_Country4PX161201190100History of Previous Travel - Country 44N/A
PX161201_Previous_Travel_Country4_ThisYearPX161201190201History of Previous Travel - Country 4 - Check if travelled to country this year.4N/A
PX161201_Previous_Travel_Country4_LastYearPX161201190202History of Previous Travel - Country 4 - Check if travelled to country last year.4N/A
PX161201_Previous_Travel_Country4_TwoYearsAgoPX161201190203History of Previous Travel - Country 4 - Check if travelled to country two years ago.4N/A
PX161201_Previous_Travel_Country4_ThreeYearsAgoPX161201190204History of Previous Travel - Country 4 - Check if travelled to country three years ago.4N/A
PX161201_Previous_Travel_Country4_FourYearsAgoPX161201190205History of Previous Travel - Country 4 - Check if travelled to country four years ago.4N/A
PX161201_Previous_Travel_Country4_FiveYearsAgoPX161201190206History of Previous Travel - Country 4 - Check if travelled to country five years ago.4N/A
PX161201_Previous_Travel_Country4_30daysThisYearPX161201190300History of Previous Travel - Country 4 - Stay was longer than 30 consecutive days this year4N/A
PX161201_Previous_Travel_Country4_30daysLastYearPX161201190400History of Previous Travel - Country 4 - Stay was longer than 30 consecutive days last year4N/A
PX161201_Previous_Travel_Country4_30daysTwoYearsAgoPX161201190500History of Previous Travel - Country 4 - Stay was longer than 30 consecutive days two years ago4N/A
PX161201_Previous_Travel_Country4_30daysThreeYearsAgoPX161201190600History of Previous Travel - Country 4 - Stay was longer than 30 consecutive days three years ago4N/A
PX161201_Previous_Travel_Country4_30daysFourYearsAgoPX161201190700History of Previous Travel - Country 4 - Stay was longer than 30 consecutive days four years ago4N/A
PX161201_Previous_Travel_Country4_30daysFiveYearsAgoPX161201190800History of Previous Travel - Country 4 - Stay was longer than 30 consecutive days five years ago4N/A
PX161201_Previous_Travel_Country5PX161201200100History of Previous Travel - Country 54N/A
PX161201_Previous_Travel_Country5_ThisYearPX161201200201History of Previous Travel - Country 5 - Check if travelled to country this year.4N/A
PX161201_Previous_Travel_Country5_LastYearPX161201200202History of Previous Travel - Country 5 - Check if travelled to country last year.4N/A
PX161201_Previous_Travel_Country5_TwoYearsAgoPX161201200203History of Previous Travel - Country 5 - Check if travelled to country two years ago.4N/A
PX161201_Previous_Travel_Country5_ThreeYearsAgoPX161201200204History of Previous Travel - Country 5 - Check if travelled to country three years ago.4N/A
PX161201_Previous_Travel_Country5_FourYearsAgoPX161201200205History of Previous Travel - Country 5 - Check if travelled to country four years ago.4N/A
PX161201_Previous_Travel_Country5_FiveYearsAgoPX161201200206History of Previous Travel - Country 5 - Check if travelled to country five years ago.4N/A
PX161201_Previous_Travel_Country5_30daysThisYearPX161201200300History of Previous Travel - Country 5 - Stay was longer than 30 consecutive days this year4N/A
PX161201_Previous_Travel_Country5_30daysLastYearPX161201200400History of Previous Travel - Country 5 - Stay was longer than 30 consecutive days last year4N/A
PX161201_Previous_Travel_Country5_30daysTwoYearsAgoPX161201200500History of Previous Travel - Country 5 - Stay was longer than 30 consecutive days two years ago4N/A
PX161201_Previous_Travel_Country5_30daysThreeYearsAgoPX161201200600History of Previous Travel - Country 5 - Stay was longer than 30 consecutive days three years ago4N/A
PX161201_Previous_Travel_Country5_30daysFourYearsAgoPX161201200700History of Previous Travel - Country 5 - Stay was longer than 30 consecutive days four years ago4N/A
PX161201_Previous_Travel_Country5_30daysFiveYearsAgoPX161201200800History of Previous Travel - Country 5 - Stay was longer than 30 consecutive days five years ago4N/A
PX161201_Previous_Travel_Country6PX161201210100History of Previous Travel - Country 64N/A
PX161201_Previous_Travel_Country6_ThisYearPX161201210201History of Previous Travel - Country 6 - Check if travelled to country this year.4N/A
PX161201_Previous_Travel_Country6_LastYearPX161201210202History of Previous Travel - Country 6 - Check if travelled to country last year.4N/A
PX161201_Previous_Travel_Country6_TwoYearsAgoPX161201210203History of Previous Travel - Country 6 - Check if travelled to country two years ago.4N/A
PX161201_Previous_Travel_Country6_ThreeYearsAgoPX161201210204History of Previous Travel - Country 6 - Check if travelled to country three years ago.4N/A
PX161201_Previous_Travel_Country6_FourYearsAgoPX161201210205History of Previous Travel - Country 6 - Check if travelled to country four years ago.4N/A
PX161201_Previous_Travel_Country6_FiveYearsAgoPX161201210206History of Previous Travel - Country 6 - Check if travelled to country five years ago.4N/A
PX161201_Previous_Travel_Country6_30daysThisYearPX161201210300History of Previous Travel - Country 6 - Stay was longer than 30 consecutive days this year4N/A
PX161201_Previous_Travel_Country6_30daysLastYearPX161201210400History of Previous Travel - Country 6 - Stay was longer than 30 consecutive days last year4N/A
PX161201_Previous_Travel_Country6_30daysTwoYearsAgoPX161201210500History of Previous Travel - Country 6 - Stay was longer than 30 consecutive days two years ago4N/A
PX161201_Previous_Travel_Country6_30daysThreeYearsAgoPX161201210600History of Previous Travel - Country 6 - Stay was longer than 30 consecutive days three years ago4N/A
PX161201_Previous_Travel_Country6_30daysFourYearsAgoPX161201210700History of Previous Travel - Country 6 - Stay was longer than 30 consecutive days four years ago4N/A
PX161201_Previous_Travel_Country6_30daysFiveYearsAgoPX161201210800History of Previous Travel - Country 6 - Stay was longer than 30 consecutive days five years ago4N/A
PX161201_ExposurePX161201220100Country of Exposure/Other4N/A
PX161201_Country1_Of_ExposurePX161201220200Country of Exposure/Other - Country 14N/A
PX161201_Country2_Of_ExposurePX161201220300Country of Exposure/Other - Country 24N/A
PX161201_More_Specific_Place_Of_ExposurePX161201230000More Specific Place of Exposure4N/A
PX161201_Reason_For_TravelPX161201240000Reason for Travel Related to Current Illness (Check One)4N/A
PX161201_Risk_Level_QualifierPX161201250000Risk Level Qualifier (Check One)4N/A
PX161201_Clinical_SettingPX161201260000Clinical Setting (Check One)4N/A
PX161201_Patient_TypePX161201270000Patient Type (Check One)4N/A
PX161201_Pretravel_Encounter_Health_Care _ProviderPX161201280000Did the patient have a pre-travel encounter with a health care provider? (Check One)4N/A
PX161201_Main_Presenting_Symptoms_AbnormalLabTestPX161201290101Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Abnormal Lab Test4N/A
PX161201_Main_Presenting_Symptoms_AsymptomaticScreeningPX161201290102Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Asymptomatic Screening4N/A
PX161201_Main_Presenting_Symptoms_CardiacPX161201290103Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Cardiac4N/A
PX161201_Main_Presenting_Symptoms_FatiguePX161201290104Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Fatigue4N/A
PX161201_Main_Presenting_Symptoms_FeverPX161201290105Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Fever4N/A
PX161201_Main_Presenting_Symptoms_GastrointestinalPX161201290106Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Gastrointestinal4N/A
PX161201_Main_Presenting_Symptoms_GenitourinaryPX161201290107Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Genitourinary4N/A
PX161201_Main_Presenting_Symptoms_HEENTPX161201290108Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): HEENT4N/A
PX161201_Main_Presenting_Symptoms_LymphaticPX161201290109Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Lymphatic4N/A
PX161201_Main_Presenting_Symptoms_MusculoskeletalPX161201290110Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Musculoskeletal4N/A
PX161201_Main_Presenting_Symptoms_NeurologicPX161201290111Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Neurologic4N/A
PX161201_Main_Presenting_Symptoms_PsychologicPX161201290112Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Psychologic4N/A
PX161201_Main_Presenting_Symptoms_RespiratoryPX161201290113Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Respiratory4N/A
PX161201_Main_Presenting_Symptoms_SkinPX161201290114Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Skin4N/A
PX161201_Main_Presenting_Symptoms_OtherPX161201290115Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Other4N/A
PX161201_Main_Presenting_Symptoms_Other_SpecifyPX161201290116Main Presenting Symptoms If "Other," Specify:4N/A
PX161201_Working_Diagnosis_1PX161201300100Working Diagnosis 14N/A
PX161201_Working_Diagnosis_1_StatusPX161201300200Working Diagnosis 1 Status (circle one)4N/A
PX161201_Working_Diagnosis_2PX161201310100Working Diagnosis 24N/A
PX161201_Working_Diagnosis_2_StatusPX161201310200Working Diagnosis 2 Status (circle one)4N/A
PX161201_Working_Diagnosis_3PX161201320100Working Diagnosis 34N/A
PX161201_Working_Diagnosis_3_StatusPX161201320200Working Diagnosis 3 Status (circle one)4N/A
PX161201_Working_Diagnosis_4PX161201330100Working Diagnosis 44N/A
PX161201_Working_Diagnosis_4_StatusPX161201330200Working Diagnosis 4 Status (circle one)4N/A
PX161201_Working_Diagnosis_5PX161201340100Working Diagnosis 54N/A
PX161201_Working_Diagnosis_5_StatusPX161201340200Working Diagnosis 5 Status (circle one)4N/A
PX161201_Working_Diagnosis_6PX161201350100Working Diagnosis 64N/A
PX161201_Working_Diagnosis_6_StatusPX161201350200Working Diagnosis 6 Status(circle one)4N/A
PX161201_Final_Diagnosis_1PX161201360100Final Diagnosis 14N/A
PX161201_Final_Diagnosis_1_StatusPX161201360200Final Diagnosis 2 Status (circle one)4N/A
PX161201_Final_Diagnosis_2PX161201370100Final Diagnosis 24N/A
PX161201_Final_Diagnosis_2_StatusPX161201370200Final Diagnosis 2 Status (circle one)4N/A
PX161201_Final_Diagnosis_3PX161201380100Final Diagnosis 34N/A
PX161201_Final_Diagnosis_3_StatusPX161201380200Final Diagnosis 3 Status (circle one)4N/A
PX161201_Final_Diagnosis_4PX161201390100Final Diagnosis 44N/A
PX161201_Final_Diagnosis_4_StatusPX161201390200Final Diagnosis 4 Status (circle one)4N/A
PX161201_Final_Diagnosis_5PX161201400100Final Diagnosis 54N/A
PX161201_Final_Diagnosis_5_StatusPX161201400200Final Diagnosis 5 Status (circle one)4N/A
PX161201_Final_Diagnosis_6PX161201410100Final Diagnosis 64N/A
PX161201_Final_Diagnosis_6_StatusPX161201410200Final Diagnosis 6 Status (circle one)4N/A
PX161201_Not_Travel_RelatedPX161201420000Check this box if patient was primarily diagnosed with an infection or disease that was acquired or existed at home prior to departure or which was acquired after travel but prior to the clinic visit.4N/A