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Medical Fitness to Travel Assessment Form

A physician completed a fitness to travel assessment form for a patient. The form included the patient's name, date of birth, and ID number. The physician checked boxes to indicate whether various body systems like eyes/ears/nose/throat and cardiovascular system were normal or abnormal. Vital signs like respiratory rate, blood pressure, and temperature were recorded. The form also noted whether the patient had any infectious diseases, mobility issues, chronic conditions, or pregnancy. It indicated if the patient was on any medications or exposed to other health risks during travel. In remarks, the physician referred the patient for pre-departure treatment and provided recommendations.

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511 views1 page

Medical Fitness to Travel Assessment Form

A physician completed a fitness to travel assessment form for a patient. The form included the patient's name, date of birth, and ID number. The physician checked boxes to indicate whether various body systems like eyes/ears/nose/throat and cardiovascular system were normal or abnormal. Vital signs like respiratory rate, blood pressure, and temperature were recorded. The form also noted whether the patient had any infectious diseases, mobility issues, chronic conditions, or pregnancy. It indicated if the patient was on any medications or exposed to other health risks during travel. In remarks, the physician referred the patient for pre-departure treatment and provided recommendations.

Uploaded by

ferry7765
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

FITNESS TO TRAVEL ASSESSMENT FORM

To be completed by an IOM or non-IOM physician


CONFIDENTIAL
1
2
3

Surname:
Name:
Date of birth:
Female
Please check box as appropriate
Physician:
Signature:

IOM ID #:
Date of assessment:
Male
Initials:
Normal

Abnormal

1.

General appearance

2.
3.

Skin / Mucosa
Eyes/Ears/Nose/Throat

4.

Respiratory system
Respiratory Rate:________
Cardiovascular system
Blood pressure: _____/_____
Pulse Rate:_________________ regular/ irregular
Infectious/ contagious (fever, etc. )
Temperature :____________ if needed
Central nervous system (incl. epilepsy)
Apparent mental state
Mobility difficulties (musculo-skeletal system)
Chronic diseases/conditions
Genito-Urinary system

Pregnancy

Yes

Yes

Yes

No

No

No

5.
6.
7.
8.
9.
10.
11.
12

ssible) EXPOSURE13to Under medication


.
14 Other travel-related health risk:
.
Remarks:
Referred for pre-departure treatment

Date:

Comments/ remarks
special needs:

expected date of delivery:


if yes, specify details:

ICD/code diagnosis:
Yes

No

Recommendation/
Treatment:

For non-IOM physicians: the completed form should be forwarded to the nearest IOM physician
in Indonesia for further advice and endorsement.

for

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