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Protocol - International Travel History

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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.

Protocol Name from Source:

The Expert Review Panel has not reviewed this measure yet.

Availability:

Publicly available

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
Major equipment No
Specialized training Yes
Specialized requirements for biospecimen collection No
Average time of greater than 15 minutes in an unaffected individual No
Mode of Administration

Self-administered questionnaire and clinical assessment

Life Stage:

Adult

Participants:

Adults, aged 18 years and older

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.

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 Text 3151204 CDE Browser
Logical Observation Identifiers Names and Codes (LOINC) International travel hx proto 62888-3 LOINC
Derived Variables

None

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_Age PX161201020000 Age 4 N/A
PX161201_Clinical_Setting PX161201260000 Clinical Setting (Check One) 4 N/A
PX161201_Country1_Of_Exposure PX161201220200 Country of Exposure/Other - Country 1 4 N/A
PX161201_Country2_Of_Exposure PX161201220300 Country of Exposure/Other - Country 2 4 N/A
PX161201_Country_Of_Birth PX161201040000 Country of Birth 4 N/A
PX161201_Country_Of_Citizenship PX161201060000 Country of Citizenship 4 N/A
PX161201_Country_Of_Current_Residence PX161201070000 Country of Current Residence 4 N/A
PX161201_Date_Arrived_US_Day PX161201090200 If you were not born in USA, indicate as closely as possible the date you first arrived here: Enter Day 4 N/A
PX161201_Date_Arrived_US_Month PX161201090100 If you were not born in USA, indicate as closely as possible the date you first arrived here: Enter Month 4 N/A
PX161201_Date_Arrived_US_Year PX161201090300 If you were not born in USA, indicate as closely as possible the date you first arrived here: Enter Year 4 N/A
PX161201_Date_Day PX161201030200 Today's Date (Clinic Visit Date) - Month 4 N/A
PX161201_Date_Month PX161201030100 Today's Date (Clinic Visit Date) - Day 4 N/A
PX161201_Date_Year PX161201030300 Today's Date (Clinic Visit Date) - Year 4 N/A
PX161201_Exposure PX161201220100 Country of Exposure/Other 4 N/A
PX161201_Final_Diagnosis_1 PX161201360100 Final Diagnosis 1 4 N/A
PX161201_Final_Diagnosis_1_Status PX161201360200 Final Diagnosis 2 Status (circle one) 4 N/A
PX161201_Final_Diagnosis_2 PX161201370100 Final Diagnosis 2 4 N/A
PX161201_Final_Diagnosis_2_Status PX161201370200 Final Diagnosis 2 Status (circle one) 4 N/A
PX161201_Final_Diagnosis_3 PX161201380100 Final Diagnosis 3 4 N/A
PX161201_Final_Diagnosis_3_Status PX161201380200 Final Diagnosis 3 Status (circle one) 4 N/A
PX161201_Final_Diagnosis_4 PX161201390100 Final Diagnosis 4 4 N/A
PX161201_Final_Diagnosis_4_Status PX161201390200 Final Diagnosis 4 Status (circle one) 4 N/A
PX161201_Final_Diagnosis_5 PX161201400100 Final Diagnosis 5 4 N/A
PX161201_Final_Diagnosis_5_Status PX161201400200 Final Diagnosis 5 Status (circle one) 4 N/A
PX161201_Final_Diagnosis_6 PX161201410100 Final Diagnosis 6 4 N/A
PX161201_Final_Diagnosis_6_Status PX161201410200 Final Diagnosis 6 Status (circle one) 4 N/A
PX161201_Gender PX161201010000 Gender 4 N/A
PX161201_Immigrant PX161201080000 Immigrant 4 N/A
PX161201_Main_Presenting_Symptoms_AbnormalLabTest PX161201290101 Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Abnormal Lab Test 4 N/A
PX161201_Main_Presenting_Symptoms_AsymptomaticScreening PX161201290102 Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Asymptomatic Screening 4 N/A
PX161201_Main_Presenting_Symptoms_Cardiac PX161201290103 Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Cardiac 4 N/A
PX161201_Main_Presenting_Symptoms_Fatigue PX161201290104 Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Fatigue 4 N/A
PX161201_Main_Presenting_Symptoms_Fever PX161201290105 Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Fever 4 N/A
PX161201_Main_Presenting_Symptoms_Gastrointestinal PX161201290106 Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Gastrointestinal 4 N/A
PX161201_Main_Presenting_Symptoms_Genitourinary PX161201290107 Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Genitourinary 4 N/A
PX161201_Main_Presenting_Symptoms_HEENT PX161201290108 Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): HEENT 4 N/A
PX161201_Main_Presenting_Symptoms_Lymphatic PX161201290109 Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Lymphatic 4 N/A
PX161201_Main_Presenting_Symptoms_Musculoskeletal PX161201290110 Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Musculoskeletal 4 N/A
PX161201_Main_Presenting_Symptoms_Neurologic PX161201290111 Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Neurologic 4 N/A
PX161201_Main_Presenting_Symptoms_Other PX161201290115 Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Other 4 N/A
PX161201_Main_Presenting_Symptoms_Other_Specify PX161201290116 Main Presenting Symptoms If "Other," Specify: 4 N/A
PX161201_Main_Presenting_Symptoms_Psychologic PX161201290112 Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Psychologic 4 N/A
PX161201_Main_Presenting_Symptoms_Respiratory PX161201290113 Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Respiratory 4 N/A
PX161201_Main_Presenting_Symptoms_Skin PX161201290114 Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply): Skin 4 N/A
PX161201_More_Specific_Place_Of_Exposure PX161201230000 More Specific Place of Exposure 4 N/A
PX161201_Not_Travel_Related PX161201420000 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. 4 N/A
PX161201_Patient_Type PX161201270000 Patient Type (Check One) 4 N/A
PX161201_Pretravel_Encounter_Health_Care _Provider PX161201280000 Did the patient have a pre-travel encounter with a health care provider? (Check One) 4 N/A
PX161201_Previous_Travel_Country1 PX161201160100 History of Previous Travel - Country 1 4 N/A
PX161201_Previous_Travel_Country1_30daysFiveYearsAgo PX161201160800 History of Previous Travel - Country 1 - Stay was longer than 30 consecutive days five years ago 4 N/A
PX161201_Previous_Travel_Country1_30daysFourYearsAgo PX161201160700 History of Previous Travel - Country 1 - Stay was longer than 30 consecutive days four years ago 4 N/A
PX161201_Previous_Travel_Country1_30daysLastYear PX161201160400 History of Previous Travel - Country 1 - Stay was longer than 30 consecutive days last year 4 N/A
PX161201_Previous_Travel_Country1_30daysThisYear PX161201160300 History of Previous Travel - Country 1 - Stay was longer than 30 consecutive days this year 4 N/A
PX161201_Previous_Travel_Country1_30daysThreeYearsAgo PX161201160600 History of Previous Travel - Country 1 - Stay was longer than 30 consecutive days three years ago 4 N/A
PX161201_Previous_Travel_Country1_30daysTwoYearsAgo PX161201160500 History of Previous Travel - Country 1 - Stay was longer than 30 consecutive days two years ago 4 N/A
PX161201_Previous_Travel_Country1_FiveYearsAgo PX161201160206 History of Previous Travel - Country 1 - Check if travelled to country five years ago. 4 N/A
PX161201_Previous_Travel_Country1_FourYearsAgo PX161201160205 History of Previous Travel - Country 1 - Check if travelled to country four years ago. 4 N/A
PX161201_Previous_Travel_Country1_LastYear PX161201160202 History of Previous Travel - Country 1 - Check if travelled to country last year. 4 N/A
PX161201_Previous_Travel_Country1_ThisYear PX161201160201 History of Previous Travel - Country 1 - Check if travelled to country this year. 4 N/A
PX161201_Previous_Travel_Country1_ThreeYearsAgo PX161201160204 History of Previous Travel - Country 1 - Check if travelled to country three years ago. 4 N/A
PX161201_Previous_Travel_Country1_TwoYearsAgo PX161201160203 History of Previous Travel - Country 1 - Check if travelled to country two years ago. 4 N/A
PX161201_Previous_Travel_Country2 PX161201170100 History of Previous Travel - Country 2 4 N/A
PX161201_Previous_Travel_Country2_30daysFiveYearsAgo PX161201170800 History of Previous Travel - Country 2 - Stay was longer than 30 consecutive days five years ago 4 N/A
PX161201_Previous_Travel_Country2_30daysFourYearsAgo PX161201170700 History of Previous Travel - Country 2 - Stay was longer than 30 consecutive days four years ago 4 N/A
PX161201_Previous_Travel_Country2_30daysLastYear PX161201170400 History of Previous Travel - Country 2 - Stay was longer than 30 consecutive days last year 4 N/A
PX161201_Previous_Travel_Country2_30daysThisYear PX161201170300 History of Previous Travel - Country 2 - Stay was longer than 30 consecutive days this year 4 N/A
PX161201_Previous_Travel_Country2_30daysThreeYearsAgo PX161201170600 History of Previous Travel - Country 2 - Stay was longer than 30 consecutive days three years ago 4 N/A
PX161201_Previous_Travel_Country2_30daysTwoYearsAgo PX161201170500 History of Previous Travel - Country 2 - Stay was longer than 30 consecutive days two years ago 4 N/A
PX161201_Previous_Travel_Country2_FiveYearsAgo PX161201170206 History of Previous Travel - Country 2 - Check if travelled to country five years ago. 4 N/A
PX161201_Previous_Travel_Country2_FourYearsAgo PX161201170205 History of Previous Travel - Country 2 - Check if travelled to country four years ago. 4 N/A
PX161201_Previous_Travel_Country2_LastYear PX161201170202 History of Previous Travel - Country 2 - Check if travelled to country last year. 4 N/A
PX161201_Previous_Travel_Country2_ThisYear PX161201170201 History of Previous Travel - Country 2 - Check if travelled to country this year. 4 N/A
PX161201_Previous_Travel_Country2_ThreeYearsAgo PX161201170204 History of Previous Travel - Country 2 - Check if travelled to country three years ago. 4 N/A
PX161201_Previous_Travel_Country2_TwoYearsAgo PX161201170203 History of Previous Travel - Country 2 - Check if travelled to country two years ago. 4 N/A
PX161201_Previous_Travel_Country3 PX161201180100 History of Previous Travel - Country 3 4 N/A
PX161201_Previous_Travel_Country3_30daysFiveYearsAgo PX161201180800 History of Previous Travel - Country 3 - Stay was longer than 30 consecutive days five years ago 4 N/A
PX161201_Previous_Travel_Country3_30daysFourYearsAgo PX161201180700 History of Previous Travel - Country 3 - Stay was longer than 30 consecutive days four years ago 4 N/A
PX161201_Previous_Travel_Country3_30daysLastYear PX161201180400 History of Previous Travel - Country 3 - Stay was longer than 30 consecutive days last year 4 N/A
PX161201_Previous_Travel_Country3_30daysThisYear PX161201180300 History of Previous Travel - Country 3 - Stay was longer than 30 consecutive days this year 4 N/A
PX161201_Previous_Travel_Country3_30daysThreeYearsAgo PX161201180600 History of Previous Travel - Country 3 - Stay was longer than 30 consecutive days three years ago 4 N/A
PX161201_Previous_Travel_Country3_30daysTwoYearsAgo PX161201180500 History of Previous Travel - Country 3 - Stay was longer than 30 consecutive days two years ago 4 N/A
PX161201_Previous_Travel_Country3_FiveYearsAgo PX161201180206 History of Previous Travel - Country 3 - Check if travelled to country five years ago. 4 N/A
PX161201_Previous_Travel_Country3_FourYearsAgo PX161201180205 History of Previous Travel - Country 3 - Check if travelled to country four years ago. 4 N/A
PX161201_Previous_Travel_Country3_LastYear PX161201180202 History of Previous Travel - Country 3 - Check if travelled to country last year. 4 N/A
PX161201_Previous_Travel_Country3_ThisYear PX161201180201 History of Previous Travel - Country 3 - Check if travelled to country this year. 4 N/A
PX161201_Previous_Travel_Country3_ThreeYearsAgo PX161201180204 History of Previous Travel - Country 3 - Check if travelled to country three years ago. 4 N/A
PX161201_Previous_Travel_Country3_TwoYearsAgo PX161201180203 History of Previous Travel - Country 3 - Check if travelled to country two years ago. 4 N/A
PX161201_Previous_Travel_Country4 PX161201190100 History of Previous Travel - Country 4 4 N/A
PX161201_Previous_Travel_Country4_30daysFiveYearsAgo PX161201190800 History of Previous Travel - Country 4 - Stay was longer than 30 consecutive days five years ago 4 N/A
PX161201_Previous_Travel_Country4_30daysFourYearsAgo PX161201190700 History of Previous Travel - Country 4 - Stay was longer than 30 consecutive days four years ago 4 N/A
PX161201_Previous_Travel_Country4_30daysLastYear PX161201190400 History of Previous Travel - Country 4 - Stay was longer than 30 consecutive days last year 4 N/A
PX161201_Previous_Travel_Country4_30daysThisYear PX161201190300 History of Previous Travel - Country 4 - Stay was longer than 30 consecutive days this year 4 N/A
PX161201_Previous_Travel_Country4_30daysThreeYearsAgo PX161201190600 History of Previous Travel - Country 4 - Stay was longer than 30 consecutive days three years ago 4 N/A
PX161201_Previous_Travel_Country4_30daysTwoYearsAgo PX161201190500 History of Previous Travel - Country 4 - Stay was longer than 30 consecutive days two years ago 4 N/A
PX161201_Previous_Travel_Country4_FiveYearsAgo PX161201190206 History of Previous Travel - Country 4 - Check if travelled to country five years ago. 4 N/A
PX161201_Previous_Travel_Country4_FourYearsAgo PX161201190205 History of Previous Travel - Country 4 - Check if travelled to country four years ago. 4 N/A
PX161201_Previous_Travel_Country4_LastYear PX161201190202 History of Previous Travel - Country 4 - Check if travelled to country last year. 4 N/A
PX161201_Previous_Travel_Country4_ThisYear PX161201190201 History of Previous Travel - Country 4 - Check if travelled to country this year. 4 N/A
PX161201_Previous_Travel_Country4_ThreeYearsAgo PX161201190204 History of Previous Travel - Country 4 - Check if travelled to country three years ago. 4 N/A
PX161201_Previous_Travel_Country4_TwoYearsAgo PX161201190203 History of Previous Travel - Country 4 - Check if travelled to country two years ago. 4 N/A
PX161201_Previous_Travel_Country5 PX161201200100 History of Previous Travel - Country 5 4 N/A
PX161201_Previous_Travel_Country5_30daysFiveYearsAgo PX161201200800 History of Previous Travel - Country 5 - Stay was longer than 30 consecutive days five years ago 4 N/A
PX161201_Previous_Travel_Country5_30daysFourYearsAgo PX161201200700 History of Previous Travel - Country 5 - Stay was longer than 30 consecutive days four years ago 4 N/A
PX161201_Previous_Travel_Country5_30daysLastYear PX161201200400 History of Previous Travel - Country 5 - Stay was longer than 30 consecutive days last year 4 N/A
PX161201_Previous_Travel_Country5_30daysThisYear PX161201200300 History of Previous Travel - Country 5 - Stay was longer than 30 consecutive days this year 4 N/A
PX161201_Previous_Travel_Country5_30daysThreeYearsAgo PX161201200600 History of Previous Travel - Country 5 - Stay was longer than 30 consecutive days three years ago 4 N/A
PX161201_Previous_Travel_Country5_30daysTwoYearsAgo PX161201200500 History of Previous Travel - Country 5 - Stay was longer than 30 consecutive days two years ago 4 N/A
PX161201_Previous_Travel_Country5_FiveYearsAgo PX161201200206 History of Previous Travel - Country 5 - Check if travelled to country five years ago. 4 N/A
PX161201_Previous_Travel_Country5_FourYearsAgo PX161201200205 History of Previous Travel - Country 5 - Check if travelled to country four years ago. 4 N/A
PX161201_Previous_Travel_Country5_LastYear PX161201200202 History of Previous Travel - Country 5 - Check if travelled to country last year. 4 N/A
PX161201_Previous_Travel_Country5_ThisYear PX161201200201 History of Previous Travel - Country 5 - Check if travelled to country this year. 4 N/A
PX161201_Previous_Travel_Country5_ThreeYearsAgo PX161201200204 History of Previous Travel - Country 5 - Check if travelled to country three years ago. 4 N/A
PX161201_Previous_Travel_Country5_TwoYearsAgo PX161201200203 History of Previous Travel - Country 5 - Check if travelled to country two years ago. 4 N/A
PX161201_Previous_Travel_Country6 PX161201210100 History of Previous Travel - Country 6 4 N/A
PX161201_Previous_Travel_Country6_30daysFiveYearsAgo PX161201210800 History of Previous Travel - Country 6 - Stay was longer than 30 consecutive days five years ago 4 N/A
PX161201_Previous_Travel_Country6_30daysFourYearsAgo PX161201210700 History of Previous Travel - Country 6 - Stay was longer than 30 consecutive days four years ago 4 N/A
PX161201_Previous_Travel_Country6_30daysLastYear PX161201210400 History of Previous Travel - Country 6 - Stay was longer than 30 consecutive days last year 4 N/A
PX161201_Previous_Travel_Country6_30daysThisYear PX161201210300 History of Previous Travel - Country 6 - Stay was longer than 30 consecutive days this year 4 N/A
PX161201_Previous_Travel_Country6_30daysThreeYearsAgo PX161201210600 History of Previous Travel - Country 6 - Stay was longer than 30 consecutive days three years ago 4 N/A
PX161201_Previous_Travel_Country6_30daysTwoYearsAgo PX161201210500 History of Previous Travel - Country 6 - Stay was longer than 30 consecutive days two years ago 4 N/A
PX161201_Previous_Travel_Country6_FiveYearsAgo PX161201210206 History of Previous Travel - Country 6 - Check if travelled to country five years ago. 4 N/A
PX161201_Previous_Travel_Country6_FourYearsAgo PX161201210205 History of Previous Travel - Country 6 - Check if travelled to country four years ago. 4 N/A
PX161201_Previous_Travel_Country6_LastYear PX161201210202 History of Previous Travel - Country 6 - Check if travelled to country last year. 4 N/A
PX161201_Previous_Travel_Country6_ThisYear PX161201210201 History of Previous Travel - Country 6 - Check if travelled to country this year. 4 N/A
PX161201_Previous_Travel_Country6_ThreeYearsAgo PX161201210204 History of Previous Travel - Country 6 - Check if travelled to country three years ago. 4 N/A
PX161201_Previous_Travel_Country6_TwoYearsAgo PX161201210203 History of Previous Travel - Country 6 - Check if travelled to country two years ago. 4 N/A
PX161201_Primary_Country _Before _10 PX161201050000 Primary Country of Residency Before Age 10 4 N/A
PX161201_Reason_For_Travel PX161201240000 Reason for Travel Related to Current Illness (Check One) 4 N/A
PX161201_Recent_Travel_Trip1_Country_1 PX161201100700 History of Recent Travel - Trip 1 - Country 1 4 N/A
PX161201_Recent_Travel_Trip1_Country_2 PX161201100800 History of Recent Travel - Trip 1 - Country 2 4 N/A
PX161201_Recent_Travel_Trip1_Country_3 PX161201100900 History of Recent Travel - Trip 1 - Country 3 4 N/A
PX161201_Recent_Travel_Trip1_Country_4 PX161201101000 History of Recent Travel - Trip 1 - Country 4 4 N/A
PX161201_Recent_Travel_Trip1_Country_5 PX161201100000 History of Recent Travel - Trip 1 - Country 5 4 N/A
PX161201_Recent_Travel_Trip1_End_Day PX161201100500 History of Recent Travel - Trip 1 End Date - Day 4 N/A
PX161201_Recent_Travel_Trip1_End_Month PX161201100400 History of Recent Travel - Trip 1 End Date - Month 4 N/A
PX161201_Recent_Travel_Trip1_End_Year PX161201100600 History of Recent Travel - Trip 1 End Date - Year 4 N/A
PX161201_Recent_Travel_Trip1_Start_Day PX161201100200 History of Recent Travel - Trip 1 Start Date - Day 4 N/A
PX161201_Recent_Travel_Trip1_Start_Month PX161201100100 History of Recent Travel - Trip 1 Start Date - Month 4 N/A
PX161201_Recent_Travel_Trip1_Start_Year PX161201100300 History of Recent Travel - Trip 1 Start Date - Year 4 N/A
PX161201_Recent_Travel_Trip2_Country_1 PX161201110700 History of Recent Travel - Trip 2 - Country 1 4 N/A
PX161201_Recent_Travel_Trip2_Country_2 PX161201110800 History of Recent Travel - Trip 2 - Country 2 4 N/A
PX161201_Recent_Travel_Trip2_Country_3 PX161201110900 History of Recent Travel - Trip 2 - Country 3 4 N/A
PX161201_Recent_Travel_Trip2_Country_4 PX161201111000 History of Recent Travel - Trip 2 - Country 4 4 N/A
PX161201_Recent_Travel_Trip2_Country_5 PX161201110000 History of Recent Travel - Trip 2 - Country 5 4 N/A
PX161201_Recent_Travel_Trip2_End_Day PX161201110500 History of Recent Travel - Trip 2 End Date - Day 4 N/A
PX161201_Recent_Travel_Trip2_End_Month PX161201110400 History of Recent Travel - Trip 2 End Date - Month 4 N/A
PX161201_Recent_Travel_Trip2_End_Year PX161201110600 History of Recent Travel - Trip 2 End Date - Year 4 N/A
PX161201_Recent_Travel_Trip2_Start_Day PX161201110200 History of Recent Travel - Trip 2 Start Date - Day 4 N/A
PX161201_Recent_Travel_Trip2_Start_Month PX161201110100 History of Recent Travel - Trip 2 Start Date - Month 4 N/A
PX161201_Recent_Travel_Trip2_Start_Year PX161201110300 History of Recent Travel - Trip 2 Start Date - Year 4 N/A
PX161201_Recent_Travel_Trip3_Country_1 PX161201120700 History of Recent Travel - Trip 3 - Country 1 4 N/A
PX161201_Recent_Travel_Trip3_Country_2 PX161201120800 History of Recent Travel - Trip 3 - Country 2 4 N/A
PX161201_Recent_Travel_Trip3_Country_3 PX161201120900 History of Recent Travel - Trip 3 - Country 3 4 N/A
PX161201_Recent_Travel_Trip3_Country_4 PX161201121000 History of Recent Travel - Trip 3 - Country 4 4 N/A
PX161201_Recent_Travel_Trip3_Country_5 PX161201120000 History of Recent Travel - Trip 3 - Country 5 4 N/A
PX161201_Recent_Travel_Trip3_End_Day PX161201120500 History of Recent Travel - Trip 3 End Date - Day 4 N/A
PX161201_Recent_Travel_Trip3_End_Month PX161201120400 History of Recent Travel - Trip 3 End Date - Month 4 N/A
PX161201_Recent_Travel_Trip3_End_Year PX161201120600 History of Recent Travel - Trip 3 End Date - Year 4 N/A
PX161201_Recent_Travel_Trip3_Start_Day PX161201120200 History of Recent Travel - Trip 3 Start Date - Day 4 N/A
PX161201_Recent_Travel_Trip3_Start_Month PX161201120100 History of Recent Travel - Trip 3 Start Date - Month 4 N/A
PX161201_Recent_Travel_Trip3_Start_Year PX161201120300 History of Recent Travel - Trip 3 Start Date - Year 4 N/A
PX161201_Recent_Travel_Trip4_Country_1 PX161201130700 History of Recent Travel - Trip 4 - Country 1 4 N/A
PX161201_Recent_Travel_Trip4_Country_2 PX161201130800 History of Recent Travel - Trip 4 - Country 2 4 N/A
PX161201_Recent_Travel_Trip4_Country_3 PX161201130900 History of Recent Travel - Trip 4 - Country 3 4 N/A
PX161201_Recent_Travel_Trip4_Country_4 PX161201131000 History of Recent Travel - Trip 4 - Country 4 4 N/A
PX161201_Recent_Travel_Trip4_Country_5 PX161201130000 History of Recent Travel - Trip 4 - Country 5 4 N/A
PX161201_Recent_Travel_Trip4_End_Day PX161201130500 History of Recent Travel - Trip 4 End Date - Day 4 N/A
PX161201_Recent_Travel_Trip4_End_Month PX161201130400 History of Recent Travel - Trip 4 End Date - Month 4 N/A
PX161201_Recent_Travel_Trip4_End_Year PX161201130600 History of Recent Travel - Trip 4 End Date - Year 4 N/A
PX161201_Recent_Travel_Trip4_Start_Day PX161201130200 History of Recent Travel - Trip 4 Start Date - Day 4 N/A
PX161201_Recent_Travel_Trip4_Start_Month PX161201130100 History of Recent Travel - Trip 4 Start Date - Month 4 N/A
PX161201_Recent_Travel_Trip4_Start_Year PX161201130300 History of Recent Travel - Trip 4 Start Date - Year 4 N/A
PX161201_Recent_Travel_Trip5_Country_1 PX161201140700 History of Recent Travel - Trip 5 - Country 1 4 N/A
PX161201_Recent_Travel_Trip5_Country_2 PX161201140800 History of Recent Travel - Trip 5 - Country 2 4 N/A
PX161201_Recent_Travel_Trip5_Country_3 PX161201140900 History of Recent Travel - Trip 5 - Country 3 4 N/A
PX161201_Recent_Travel_Trip5_Country_4 PX161201141000 History of Recent Travel - Trip 5 - Country 4 4 N/A
PX161201_Recent_Travel_Trip5_Country_5 PX161201140000 History of Recent Travel - Trip 5 - Country 5 4 N/A
PX161201_Recent_Travel_Trip5_End_Day PX161201140500 History of Recent Travel - Trip 5 End Date - Day 4 N/A
PX161201_Recent_Travel_Trip5_End_Month PX161201140400 History of Recent Travel - Trip 5 End Date - Month 4 N/A
PX161201_Recent_Travel_Trip5_End_Year PX161201140600 History of Recent Travel - Trip 5 End Date - Year 4 N/A
PX161201_Recent_Travel_Trip5_Start_Day PX161201140200 History of Recent Travel - Trip 5 Start Date - Day 4 N/A
PX161201_Recent_Travel_Trip5_Start_Month PX161201140100 History of Recent Travel - Trip 5 Start Date - Month 4 N/A
PX161201_Recent_Travel_Trip5_Start_Year PX161201140300 History of Recent Travel - Trip 5 Start Date - Year 4 N/A
PX161201_Recent_Travel_Trip6_Country_1 PX161201150700 History of Recent Travel - Trip 6 - Country 1 4 N/A
PX161201_Recent_Travel_Trip6_Country_2 PX161201150800 History of Recent Travel - Trip 6 - Country 2 4 N/A
PX161201_Recent_Travel_Trip6_Country_3 PX161201150900 History of Recent Travel - Trip 6 - Country 3 4 N/A
PX161201_Recent_Travel_Trip6_Country_4 PX161201151000 History of Recent Travel - Trip 6 - Country 4 4 N/A
PX161201_Recent_Travel_Trip6_Country_5 PX161201150000 History of Recent Travel - Trip 6 - Country 5 4 N/A
PX161201_Recent_Travel_Trip6_End_Day PX161201150500 History of Recent Travel - Trip 6 End Date - Day 4 N/A
PX161201_Recent_Travel_Trip6_End_Month PX161201150400 History of Recent Travel - Trip 6 End Date - Month 4 N/A
PX161201_Recent_Travel_Trip6_End_Year PX161201150600 History of Recent Travel - Trip 6 End Date - Year 4 N/A
PX161201_Recent_Travel_Trip6_Start_Day PX161201150200 History of Recent Travel - Trip 6 Start Date - Day 4 N/A
PX161201_Recent_Travel_Trip6_Start_Month PX161201150100 History of Recent Travel - Trip 6 Start Date - Month 4 N/A
PX161201_Recent_Travel_Trip6_Start_Year PX161201150300 History of Recent Travel - Trip 6 Start Date - Year 4 N/A
PX161201_Risk_Level_Qualifier PX161201250000 Risk Level Qualifier (Check One) 4 N/A
PX161201_Working_Diagnosis_1 PX161201300100 Working Diagnosis 1 4 N/A
PX161201_Working_Diagnosis_1_Status PX161201300200 Working Diagnosis 1 Status (circle one) 4 N/A
PX161201_Working_Diagnosis_2 PX161201310100 Working Diagnosis 2 4 N/A
PX161201_Working_Diagnosis_2_Status PX161201310200 Working Diagnosis 2 Status (circle one) 4 N/A
PX161201_Working_Diagnosis_3 PX161201320100 Working Diagnosis 3 4 N/A
PX161201_Working_Diagnosis_3_Status PX161201320200 Working Diagnosis 3 Status (circle one) 4 N/A
PX161201_Working_Diagnosis_4 PX161201330100 Working Diagnosis 4 4 N/A
PX161201_Working_Diagnosis_4_Status PX161201330200 Working Diagnosis 4 Status (circle one) 4 N/A
PX161201_Working_Diagnosis_5 PX161201340100 Working Diagnosis 5 4 N/A
PX161201_Working_Diagnosis_5_Status PX161201340200 Working Diagnosis 5 Status (circle one) 4 N/A
PX161201_Working_Diagnosis_6 PX161201350100 Working Diagnosis 6 4 N/A
PX161201_Working_Diagnosis_6_Status PX161201350200 Working Diagnosis 6 Status(circle one) 4 N/A
Research Domain Information
Measure Name:

International Travel History

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.

Keywords

Travel history, Infectious disease, Infectious Diseases and Immunity