Protocol - International Travel History
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 respondents 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.
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.
Availability
Protocol
1. General Information | Gender | Age | *Todays Date Month/Day/Year | |
*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 |
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 | *Trip End Date | *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 | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | |||||
Check if stay was >30 consecutive days | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | |||||
*Country: | 4 | 5 | 6 | ||||||||||||||||||||
*Check each year of travel to the country | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | [ ] | |||||
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 | ||||||||||||||||||||||||
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):
| ||||||||||||||||||||||||
Risk Level Qualifier (Check One): [ ] Pre-Arranged or Organized Travel [ ] Risk Travel | ||||||||||||||||||||||||
*Clinical Setting (Check One): [ ] Seen During Travel [ ] Seen After Travel | ||||||||||||||||||||||||
*Patient Type(Check One): [ ] Inpatient [ ] Outpatient [ ] TeleConsult-Outpatient | ||||||||||||||||||||||||
Did the patient have a pre-travel encounter with a health care provider? (Check One): | ||||||||||||||||||||||||
*Main Presenting Symptoms (Check at least one symptom below, but include all symptoms that apply):
| ||||||||||||||||||||||||
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; | ||||||||||||||||||||||||
[ ] 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 Category | Required |
---|---|
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
Lifestage
Adult
Participants
Adults, aged 18 years and older
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
Standard | Name | ID | Source |
---|---|---|---|
Logical Observation Identifiers Names and Codes (LOINC) | International travel hx proto | 62888-3 | LOINC |
caDSR Form | PhenX PX161201 - International Travel History | 6257520 | caDSR Form |
Derived Variables
None
Process and Review
Not applicable.
Protocol Name from Source
Centers for Disease Control and Prevention (CDC), GeoSentinel Questionnaire, 2008
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 VariablesVariable Name | Variable ID | Variable Description | dbGaP Mapping | |
---|---|---|---|---|
PX161201_Age | ||||
PX161201020000 | Age | Variable Mapping | ||
PX161201_Clinical_Setting | ||||
PX161201260000 | Clinical Setting (Check One) | N/A | ||
PX161201_Country1_Of_Exposure | ||||
PX161201220200 | Country of Exposure/Other - Country 1 | N/A | ||
PX161201_Country2_Of_Exposure | ||||
PX161201220300 | Country of Exposure/Other - Country 2 | N/A | ||
PX161201_Country_Of_Birth | ||||
PX161201040000 | Country of Birth | Variable Mapping | ||
PX161201_Country_Of_Citizenship | ||||
PX161201060000 | Country of Citizenship | N/A | ||
PX161201_Country_Of_Current_Residence | ||||
PX161201070000 | Country of Current Residence | Variable Mapping | ||
PX161201_Date_Arrived_US_Day | ||||
PX161201090200 | If you were not born in USA, indicate as more | N/A | ||
PX161201_Date_Arrived_US_Month | ||||
PX161201090100 | If you were not born in USA, indicate as more | N/A | ||
PX161201_Date_Arrived_US_Year | ||||
PX161201090300 | If you were not born in USA, indicate as more | N/A | ||
PX161201_Date_Day | ||||
PX161201030100 | Today's Date (Clinic Visit Date) - Day | N/A | ||
PX161201_Date_Month | ||||
PX161201030200 | Today's Date (Clinic Visit Date) - Month | N/A | ||
PX161201_Date_Year | ||||
PX161201030300 | Today's Date (Clinic Visit Date) - Year | N/A | ||
PX161201_Exposure | ||||
PX161201220100 | Country of Exposure/Other | N/A | ||
PX161201_Final_Diagnosis_1 | ||||
PX161201360100 | Final Diagnosis 1 | N/A | ||
PX161201_Final_Diagnosis_1_Status | ||||
PX161201360200 | Final Diagnosis 2 Status (circle one) | N/A | ||
PX161201_Final_Diagnosis_2 | ||||
PX161201370100 | Final Diagnosis 2 | N/A | ||
PX161201_Final_Diagnosis_2_Status | ||||
PX161201370200 | Final Diagnosis 2 Status (circle one) | N/A | ||
PX161201_Final_Diagnosis_3 | ||||
PX161201380100 | Final Diagnosis 3 | N/A | ||
PX161201_Final_Diagnosis_3_Status | ||||
PX161201380200 | Final Diagnosis 3 Status (circle one) | N/A | ||
PX161201_Final_Diagnosis_4 | ||||
PX161201390100 | Final Diagnosis 4 | N/A | ||
PX161201_Final_Diagnosis_4_Status | ||||
PX161201390200 | Final Diagnosis 4 Status (circle one) | N/A | ||
PX161201_Final_Diagnosis_5 | ||||
PX161201400100 | Final Diagnosis 5 | N/A | ||
PX161201_Final_Diagnosis_5_Status | ||||
PX161201400200 | Final Diagnosis 5 Status (circle one) | N/A | ||
PX161201_Final_Diagnosis_6 | ||||
PX161201410100 | Final Diagnosis 6 | N/A | ||
PX161201_Final_Diagnosis_6_Status | ||||
PX161201410200 | Final Diagnosis 6 Status (circle one) | N/A | ||
PX161201_Gender | ||||
PX161201010000 | Gender | Variable Mapping | ||
PX161201_Immigrant | ||||
PX161201080000 | Immigrant | N/A | ||
PX161201_Main_Presenting_Symptoms_AbnormalLabTest | ||||
PX161201290101 | Main Presenting Symptoms (Check at least one more | N/A | ||
PX161201_Main_Presenting_Symptoms_AsymptomaticScreening | ||||
PX161201290102 | Main Presenting Symptoms (Check at least one more | N/A | ||
PX161201_Main_Presenting_Symptoms_Cardiac | ||||
PX161201290103 | Main Presenting Symptoms (Check at least one more | N/A | ||
PX161201_Main_Presenting_Symptoms_Fatigue | ||||
PX161201290104 | Main Presenting Symptoms (Check at least one more | Variable Mapping | ||
PX161201_Main_Presenting_Symptoms_Fever | ||||
PX161201290105 | Main Presenting Symptoms (Check at least one more | Variable Mapping | ||
PX161201_Main_Presenting_Symptoms_Gastrointestinal | ||||
PX161201290106 | Main Presenting Symptoms (Check at least one more | N/A | ||
PX161201_Main_Presenting_Symptoms_Genitourinary | ||||
PX161201290107 | Main Presenting Symptoms (Check at least one more | Variable Mapping | ||
PX161201_Main_Presenting_Symptoms_HEENT | ||||
PX161201290108 | Main Presenting Symptoms (Check at least one more | Variable Mapping | ||
PX161201_Main_Presenting_Symptoms_Lymphatic | ||||
PX161201290109 | Main Presenting Symptoms (Check at least one more | Variable Mapping | ||
PX161201_Main_Presenting_Symptoms_Musculoskeletal | ||||
PX161201290110 | Main Presenting Symptoms (Check at least one more | Variable Mapping | ||
PX161201_Main_Presenting_Symptoms_Neurologic | ||||
PX161201290111 | Main Presenting Symptoms (Check at least one more | Variable Mapping | ||
PX161201_Main_Presenting_Symptoms_Other | ||||
PX161201290115 | Main Presenting Symptoms (Check at least one more | N/A | ||
PX161201_Main_Presenting_Symptoms_Other_Specify | ||||
PX161201290116 | Main Presenting Symptoms If Other, Specify: | N/A | ||
PX161201_Main_Presenting_Symptoms_Psychologic | ||||
PX161201290112 | Main Presenting Symptoms (Check at least one more | N/A | ||
PX161201_Main_Presenting_Symptoms_Respiratory | ||||
PX161201290113 | Main Presenting Symptoms (Check at least one more | N/A | ||
PX161201_Main_Presenting_Symptoms_Skin | ||||
PX161201290114 | Main Presenting Symptoms (Check at least one more | N/A | ||
PX161201_More_Specific_Place_Of_Exposure | ||||
PX161201230000 | More Specific Place of Exposure | N/A | ||
PX161201_Not_Travel_Related | ||||
PX161201420000 | Check this box if patient was primarily more | N/A | ||
PX161201_Patient_Type | ||||
PX161201270000 | Patient Type (Check One) | Variable Mapping | ||
PX161201_Pretravel_Encounter_Health_Care _Provider | ||||
PX161201280000 | Did the patient have a pre-travel encounter more | N/A | ||
PX161201_Previous_Travel_Country1 | ||||
PX161201160100 | History of Previous Travel - Country 1 | N/A | ||
PX161201_Previous_Travel_Country1_30daysFiveYearsAgo | ||||
PX161201160800 | History of Previous Travel - Country 1 - more | N/A | ||
PX161201_Previous_Travel_Country1_30daysFourYearsAgo | ||||
PX161201160700 | History of Previous Travel - Country 1 - more | N/A | ||
PX161201_Previous_Travel_Country1_30daysLastYear | ||||
PX161201160400 | History of Previous Travel - Country 1 - more | N/A | ||
PX161201_Previous_Travel_Country1_30daysThisYear | ||||
PX161201160300 | History of Previous Travel - Country 1 - more | N/A | ||
PX161201_Previous_Travel_Country1_30daysThreeYearsAgo | ||||
PX161201160600 | History of Previous Travel - Country 1 - more | N/A | ||
PX161201_Previous_Travel_Country1_30daysTwoYearsAgo | ||||
PX161201160500 | History of Previous Travel - Country 1 - more | N/A | ||
PX161201_Previous_Travel_Country1_FiveYearsAgo | ||||
PX161201160206 | History of Previous Travel - Country 1 - more | N/A | ||
PX161201_Previous_Travel_Country1_FourYearsAgo | ||||
PX161201160205 | History of Previous Travel - Country 1 - more | N/A | ||
PX161201_Previous_Travel_Country1_LastYear | ||||
PX161201160202 | History of Previous Travel - Country 1 - more | N/A | ||
PX161201_Previous_Travel_Country1_ThisYear | ||||
PX161201160201 | History of Previous Travel - Country 1 - more | N/A | ||
PX161201_Previous_Travel_Country1_ThreeYearsAgo | ||||
PX161201160204 | History of Previous Travel - Country 1 - more | N/A | ||
PX161201_Previous_Travel_Country1_TwoYearsAgo | ||||
PX161201160203 | History of Previous Travel - Country 1 - more | N/A | ||
PX161201_Previous_Travel_Country2 | ||||
PX161201170100 | History of Previous Travel - Country 2 | N/A | ||
PX161201_Previous_Travel_Country2_30daysFiveYearsAgo | ||||
PX161201170800 | History of Previous Travel - Country 2 - more | N/A | ||
PX161201_Previous_Travel_Country2_30daysFourYearsAgo | ||||
PX161201170700 | History of Previous Travel - Country 2 - more | N/A | ||
PX161201_Previous_Travel_Country2_30daysLastYear | ||||
PX161201170400 | History of Previous Travel - Country 2 - more | N/A | ||
PX161201_Previous_Travel_Country2_30daysThisYear | ||||
PX161201170300 | History of Previous Travel - Country 2 - more | N/A | ||
PX161201_Previous_Travel_Country2_30daysThreeYearsAgo | ||||
PX161201170600 | History of Previous Travel - Country 2 - more | N/A | ||
PX161201_Previous_Travel_Country2_30daysTwoYearsAgo | ||||
PX161201170500 | History of Previous Travel - Country 2 - more | N/A | ||
PX161201_Previous_Travel_Country2_FiveYearsAgo | ||||
PX161201170206 | History of Previous Travel - Country 2 - more | N/A | ||
PX161201_Previous_Travel_Country2_FourYearsAgo | ||||
PX161201170205 | History of Previous Travel - Country 2 - more | N/A | ||
PX161201_Previous_Travel_Country2_LastYear | ||||
PX161201170202 | History of Previous Travel - Country 2 - more | N/A | ||
PX161201_Previous_Travel_Country2_ThisYear | ||||
PX161201170201 | History of Previous Travel - Country 2 - more | N/A | ||
PX161201_Previous_Travel_Country2_ThreeYearsAgo | ||||
PX161201170204 | History of Previous Travel - Country 2 - more | N/A | ||
PX161201_Previous_Travel_Country2_TwoYearsAgo | ||||
PX161201170203 | History of Previous Travel - Country 2 - more | N/A | ||
PX161201_Previous_Travel_Country3 | ||||
PX161201180100 | History of Previous Travel - Country 3 | N/A | ||
PX161201_Previous_Travel_Country3_30daysFiveYearsAgo | ||||
PX161201180800 | History of Previous Travel - Country 3 - more | N/A | ||
PX161201_Previous_Travel_Country3_30daysFourYearsAgo | ||||
PX161201180700 | History of Previous Travel - Country 3 - more | N/A | ||
PX161201_Previous_Travel_Country3_30daysLastYear | ||||
PX161201180400 | History of Previous Travel - Country 3 - more | N/A | ||
PX161201_Previous_Travel_Country3_30daysThisYear | ||||
PX161201180300 | History of Previous Travel - Country 3 - more | N/A | ||
PX161201_Previous_Travel_Country3_30daysThreeYearsAgo | ||||
PX161201180600 | History of Previous Travel - Country 3 - more | N/A | ||
PX161201_Previous_Travel_Country3_30daysTwoYearsAgo | ||||
PX161201180500 | History of Previous Travel - Country 3 - more | N/A | ||
PX161201_Previous_Travel_Country3_FiveYearsAgo | ||||
PX161201180206 | History of Previous Travel - Country 3 - more | N/A | ||
PX161201_Previous_Travel_Country3_FourYearsAgo | ||||
PX161201180205 | History of Previous Travel - Country 3 - more | N/A | ||
PX161201_Previous_Travel_Country3_LastYear | ||||
PX161201180202 | History of Previous Travel - Country 3 - more | N/A | ||
PX161201_Previous_Travel_Country3_ThisYear | ||||
PX161201180201 | History of Previous Travel - Country 3 - more | N/A | ||
PX161201_Previous_Travel_Country3_ThreeYearsAgo | ||||
PX161201180204 | History of Previous Travel - Country 3 - more | N/A | ||
PX161201_Previous_Travel_Country3_TwoYearsAgo | ||||
PX161201180203 | History of Previous Travel - Country 3 - more | N/A | ||
PX161201_Previous_Travel_Country4 | ||||
PX161201190100 | History of Previous Travel - Country 4 | N/A | ||
PX161201_Previous_Travel_Country4_30daysFiveYearsAgo | ||||
PX161201190800 | History of Previous Travel - Country 4 - more | N/A | ||
PX161201_Previous_Travel_Country4_30daysFourYearsAgo | ||||
PX161201190700 | History of Previous Travel - Country 4 - more | N/A | ||
PX161201_Previous_Travel_Country4_30daysLastYear | ||||
PX161201190400 | History of Previous Travel - Country 4 - more | N/A | ||
PX161201_Previous_Travel_Country4_30daysThisYear | ||||
PX161201190300 | History of Previous Travel - Country 4 - more | N/A | ||
PX161201_Previous_Travel_Country4_30daysThreeYearsAgo | ||||
PX161201190600 | History of Previous Travel - Country 4 - more | N/A | ||
PX161201_Previous_Travel_Country4_30daysTwoYearsAgo | ||||
PX161201190500 | History of Previous Travel - Country 4 - more | N/A | ||
PX161201_Previous_Travel_Country4_FiveYearsAgo | ||||
PX161201190206 | History of Previous Travel - Country 4 - more | N/A | ||
PX161201_Previous_Travel_Country4_FourYearsAgo | ||||
PX161201190205 | History of Previous Travel - Country 4 - more | N/A | ||
PX161201_Previous_Travel_Country4_LastYear | ||||
PX161201190202 | History of Previous Travel - Country 4 - more | N/A | ||
PX161201_Previous_Travel_Country4_ThisYear | ||||
PX161201190201 | History of Previous Travel - Country 4 - more | N/A | ||
PX161201_Previous_Travel_Country4_ThreeYearsAgo | ||||
PX161201190204 | History of Previous Travel - Country 4 - more | N/A | ||
PX161201_Previous_Travel_Country4_TwoYearsAgo | ||||
PX161201190203 | History of Previous Travel - Country 4 - more | N/A | ||
PX161201_Previous_Travel_Country5 | ||||
PX161201200100 | History of Previous Travel - Country 5 | N/A | ||
PX161201_Previous_Travel_Country5_30daysFiveYearsAgo | ||||
PX161201200800 | History of Previous Travel - Country 5 - more | N/A | ||
PX161201_Previous_Travel_Country5_30daysFourYearsAgo | ||||
PX161201200700 | History of Previous Travel - Country 5 - more | N/A | ||
PX161201_Previous_Travel_Country5_30daysLastYear | ||||
PX161201200400 | History of Previous Travel - Country 5 - more | N/A | ||
PX161201_Previous_Travel_Country5_30daysThisYear | ||||
PX161201200300 | History of Previous Travel - Country 5 - more | N/A | ||
PX161201_Previous_Travel_Country5_30daysThreeYearsAgo | ||||
PX161201200600 | History of Previous Travel - Country 5 - more | N/A | ||
PX161201_Previous_Travel_Country5_30daysTwoYearsAgo | ||||
PX161201200500 | History of Previous Travel - Country 5 - more | N/A | ||
PX161201_Previous_Travel_Country5_FiveYearsAgo | ||||
PX161201200206 | History of Previous Travel - Country 5 - more | N/A | ||
PX161201_Previous_Travel_Country5_FourYearsAgo | ||||
PX161201200205 | History of Previous Travel - Country 5 - more | N/A | ||
PX161201_Previous_Travel_Country5_LastYear | ||||
PX161201200202 | History of Previous Travel - Country 5 - more | N/A | ||
PX161201_Previous_Travel_Country5_ThisYear | ||||
PX161201200201 | History of Previous Travel - Country 5 - more | N/A | ||
PX161201_Previous_Travel_Country5_ThreeYearsAgo | ||||
PX161201200204 | History of Previous Travel - Country 5 - more | N/A | ||
PX161201_Previous_Travel_Country5_TwoYearsAgo | ||||
PX161201200203 | History of Previous Travel - Country 5 - more | N/A | ||
PX161201_Previous_Travel_Country6 | ||||
PX161201210100 | History of Previous Travel - Country 6 | N/A | ||
PX161201_Previous_Travel_Country6_30daysFiveYearsAgo | ||||
PX161201210800 | History of Previous Travel - Country 6 - more | N/A | ||
PX161201_Previous_Travel_Country6_30daysFourYearsAgo | ||||
PX161201210700 | History of Previous Travel - Country 6 - more | N/A | ||
PX161201_Previous_Travel_Country6_30daysLastYear | ||||
PX161201210400 | History of Previous Travel - Country 6 - more | N/A | ||
PX161201_Previous_Travel_Country6_30daysThisYear | ||||
PX161201210300 | History of Previous Travel - Country 6 - more | N/A | ||
PX161201_Previous_Travel_Country6_30daysThreeYearsAgo | ||||
PX161201210600 | History of Previous Travel - Country 6 - more | N/A | ||
PX161201_Previous_Travel_Country6_30daysTwoYearsAgo | ||||
PX161201210500 | History of Previous Travel - Country 6 - more | N/A | ||
PX161201_Previous_Travel_Country6_FiveYearsAgo | ||||
PX161201210206 | History of Previous Travel - Country 6 - more | N/A | ||
PX161201_Previous_Travel_Country6_FourYearsAgo | ||||
PX161201210205 | History of Previous Travel - Country 6 - more | N/A | ||
PX161201_Previous_Travel_Country6_LastYear | ||||
PX161201210202 | History of Previous Travel - Country 6 - more | N/A | ||
PX161201_Previous_Travel_Country6_ThisYear | ||||
PX161201210201 | History of Previous Travel - Country 6 - more | N/A | ||
PX161201_Previous_Travel_Country6_ThreeYearsAgo | ||||
PX161201210204 | History of Previous Travel - Country 6 - more | N/A | ||
PX161201_Previous_Travel_Country6_TwoYearsAgo | ||||
PX161201210203 | History of Previous Travel - Country 6 - more | N/A | ||
PX161201_Primary_Country _Before _10 | ||||
PX161201050000 | Primary Country of Residency Before Age 10 | N/A | ||
PX161201_Reason_For_Travel | ||||
PX161201240000 | Reason for Travel Related to Current Illness more | N/A | ||
PX161201_Recent_Travel_Trip1_Country_1 | ||||
PX161201100700 | History of Recent Travel - Trip 1 - Country 1 | N/A | ||
PX161201_Recent_Travel_Trip1_Country_2 | ||||
PX161201100800 | History of Recent Travel - Trip 1 - Country 2 | N/A | ||
PX161201_Recent_Travel_Trip1_Country_3 | ||||
PX161201100900 | History of Recent Travel - Trip 1 - Country 3 | N/A | ||
PX161201_Recent_Travel_Trip1_Country_4 | ||||
PX161201101000 | History of Recent Travel - Trip 1 - Country 4 | N/A | ||
PX161201_Recent_Travel_Trip1_Country_5 | ||||
PX161201100000 | History of Recent Travel - Trip 1 - Country 5 | N/A | ||
PX161201_Recent_Travel_Trip1_End_Day | ||||
PX161201100500 | History of Recent Travel - Trip 1 End Date - Day | N/A | ||
PX161201_Recent_Travel_Trip1_End_Month | ||||
PX161201100400 | History of Recent Travel - Trip 1 End Date - Month | N/A | ||
PX161201_Recent_Travel_Trip1_End_Year | ||||
PX161201100600 | History of Recent Travel - Trip 1 End Date - Year | N/A | ||
PX161201_Recent_Travel_Trip1_Start_Day | ||||
PX161201100200 | History of Recent Travel - Trip 1 Start Date - Day | N/A | ||
PX161201_Recent_Travel_Trip1_Start_Month | ||||
PX161201100100 | History of Recent Travel - Trip 1 Start Date more | N/A | ||
PX161201_Recent_Travel_Trip1_Start_Year | ||||
PX161201100300 | History of Recent Travel - Trip 1 Start Date more | N/A | ||
PX161201_Recent_Travel_Trip2_Country_1 | ||||
PX161201110700 | History of Recent Travel - Trip 2 - Country 1 | N/A | ||
PX161201_Recent_Travel_Trip2_Country_2 | ||||
PX161201110800 | History of Recent Travel - Trip 2 - Country 2 | N/A | ||
PX161201_Recent_Travel_Trip2_Country_3 | ||||
PX161201110900 | History of Recent Travel - Trip 2 - Country 3 | N/A | ||
PX161201_Recent_Travel_Trip2_Country_4 | ||||
PX161201111000 | History of Recent Travel - Trip 2 - Country 4 | N/A | ||
PX161201_Recent_Travel_Trip2_Country_5 | ||||
PX161201110000 | History of Recent Travel - Trip 2 - Country 5 | N/A | ||
PX161201_Recent_Travel_Trip2_End_Day | ||||
PX161201110500 | History of Recent Travel - Trip 2 End Date - Day | N/A | ||
PX161201_Recent_Travel_Trip2_End_Month | ||||
PX161201110400 | History of Recent Travel - Trip 2 End Date - Month | N/A | ||
PX161201_Recent_Travel_Trip2_End_Year | ||||
PX161201110600 | History of Recent Travel - Trip 2 End Date - Year | N/A | ||
PX161201_Recent_Travel_Trip2_Start_Day | ||||
PX161201110200 | History of Recent Travel - Trip 2 Start Date - Day | N/A | ||
PX161201_Recent_Travel_Trip2_Start_Month | ||||
PX161201110100 | History of Recent Travel - Trip 2 Start Date more | N/A | ||
PX161201_Recent_Travel_Trip2_Start_Year | ||||
PX161201110300 | History of Recent Travel - Trip 2 Start Date more | N/A | ||
PX161201_Recent_Travel_Trip3_Country_1 | ||||
PX161201120700 | History of Recent Travel - Trip 3 - Country 1 | N/A | ||
PX161201_Recent_Travel_Trip3_Country_2 | ||||
PX161201120800 | History of Recent Travel - Trip 3 - Country 2 | N/A | ||
PX161201_Recent_Travel_Trip3_Country_3 | ||||
PX161201120900 | History of Recent Travel - Trip 3 - Country 3 | N/A | ||
PX161201_Recent_Travel_Trip3_Country_4 | ||||
PX161201121000 | History of Recent Travel - Trip 3 - Country 4 | N/A | ||
PX161201_Recent_Travel_Trip3_Country_5 | ||||
PX161201120000 | History of Recent Travel - Trip 3 - Country 5 | N/A | ||
PX161201_Recent_Travel_Trip3_End_Day | ||||
PX161201120500 | History of Recent Travel - Trip 3 End Date - Day | N/A | ||
PX161201_Recent_Travel_Trip3_End_Month | ||||
PX161201120400 | History of Recent Travel - Trip 3 End Date - Month | N/A | ||
PX161201_Recent_Travel_Trip3_End_Year | ||||
PX161201120600 | History of Recent Travel - Trip 3 End Date - Year | N/A | ||
PX161201_Recent_Travel_Trip3_Start_Day | ||||
PX161201120200 | History of Recent Travel - Trip 3 Start Date - Day | N/A | ||
PX161201_Recent_Travel_Trip3_Start_Month | ||||
PX161201120100 | History of Recent Travel - Trip 3 Start Date more | N/A | ||
PX161201_Recent_Travel_Trip3_Start_Year | ||||
PX161201120300 | History of Recent Travel - Trip 3 Start Date more | N/A | ||
PX161201_Recent_Travel_Trip4_Country_1 | ||||
PX161201130700 | History of Recent Travel - Trip 4 - Country 1 | N/A | ||
PX161201_Recent_Travel_Trip4_Country_2 | ||||
PX161201130800 | History of Recent Travel - Trip 4 - Country 2 | N/A | ||
PX161201_Recent_Travel_Trip4_Country_3 | ||||
PX161201130900 | History of Recent Travel - Trip 4 - Country 3 | N/A | ||
PX161201_Recent_Travel_Trip4_Country_4 | ||||
PX161201131000 | History of Recent Travel - Trip 4 - Country 4 | N/A | ||
PX161201_Recent_Travel_Trip4_Country_5 | ||||
PX161201130000 | History of Recent Travel - Trip 4 - Country 5 | N/A | ||
PX161201_Recent_Travel_Trip4_End_Day | ||||
PX161201130500 | History of Recent Travel - Trip 4 End Date - Day | N/A | ||
PX161201_Recent_Travel_Trip4_End_Month | ||||
PX161201130400 | History of Recent Travel - Trip 4 End Date - Month | N/A | ||
PX161201_Recent_Travel_Trip4_End_Year | ||||
PX161201130600 | History of Recent Travel - Trip 4 End Date - Year | N/A | ||
PX161201_Recent_Travel_Trip4_Start_Day | ||||
PX161201130200 | History of Recent Travel - Trip 4 Start Date - Day | N/A | ||
PX161201_Recent_Travel_Trip4_Start_Month | ||||
PX161201130100 | History of Recent Travel - Trip 4 Start Date more | N/A | ||
PX161201_Recent_Travel_Trip4_Start_Year | ||||
PX161201130300 | History of Recent Travel - Trip 4 Start Date more | N/A | ||
PX161201_Recent_Travel_Trip5_Country_1 | ||||
PX161201140700 | History of Recent Travel - Trip 5 - Country 1 | N/A | ||
PX161201_Recent_Travel_Trip5_Country_2 | ||||
PX161201140800 | History of Recent Travel - Trip 5 - Country 2 | N/A | ||
PX161201_Recent_Travel_Trip5_Country_3 | ||||
PX161201140900 | History of Recent Travel - Trip 5 - Country 3 | N/A | ||
PX161201_Recent_Travel_Trip5_Country_4 | ||||
PX161201141000 | History of Recent Travel - Trip 5 - Country 4 | N/A | ||
PX161201_Recent_Travel_Trip5_Country_5 | ||||
PX161201140000 | History of Recent Travel - Trip 5 - Country 5 | N/A | ||
PX161201_Recent_Travel_Trip5_End_Day | ||||
PX161201140500 | History of Recent Travel - Trip 5 End Date - Day | N/A | ||
PX161201_Recent_Travel_Trip5_End_Month | ||||
PX161201140400 | History of Recent Travel - Trip 5 End Date - Month | N/A | ||
PX161201_Recent_Travel_Trip5_End_Year | ||||
PX161201140600 | History of Recent Travel - Trip 5 End Date - Year | N/A | ||
PX161201_Recent_Travel_Trip5_Start_Day | ||||
PX161201140200 | History of Recent Travel - Trip 5 Start Date - Day | N/A | ||
PX161201_Recent_Travel_Trip5_Start_Month | ||||
PX161201140100 | History of Recent Travel - Trip 5 Start Date more | N/A | ||
PX161201_Recent_Travel_Trip5_Start_Year | ||||
PX161201140300 | History of Recent Travel - Trip 5 Start Date more | N/A | ||
PX161201_Recent_Travel_Trip6_Country_1 | ||||
PX161201150700 | History of Recent Travel - Trip 6 - Country 1 | N/A | ||
PX161201_Recent_Travel_Trip6_Country_2 | ||||
PX161201150800 | History of Recent Travel - Trip 6 - Country 2 | N/A | ||
PX161201_Recent_Travel_Trip6_Country_3 | ||||
PX161201150900 | History of Recent Travel - Trip 6 - Country 3 | N/A | ||
PX161201_Recent_Travel_Trip6_Country_4 | ||||
PX161201151000 | History of Recent Travel - Trip 6 - Country 4 | N/A | ||
PX161201_Recent_Travel_Trip6_Country_5 | ||||
PX161201150000 | History of Recent Travel - Trip 6 - Country 5 | N/A | ||
PX161201_Recent_Travel_Trip6_End_Day | ||||
PX161201150500 | History of Recent Travel - Trip 6 End Date - Day | N/A | ||
PX161201_Recent_Travel_Trip6_End_Month | ||||
PX161201150400 | History of Recent Travel - Trip 6 End Date - Month | N/A | ||
PX161201_Recent_Travel_Trip6_End_Year | ||||
PX161201150600 | History of Recent Travel - Trip 6 End Date - Year | N/A | ||
PX161201_Recent_Travel_Trip6_Start_Day | ||||
PX161201150200 | History of Recent Travel - Trip 6 Start Date - Day | N/A | ||
PX161201_Recent_Travel_Trip6_Start_Month | ||||
PX161201150100 | History of Recent Travel - Trip 6 Start Date more | N/A | ||
PX161201_Recent_Travel_Trip6_Start_Year | ||||
PX161201150300 | History of Recent Travel - Trip 6 Start Date more | N/A | ||
PX161201_Risk_Level_Qualifier | ||||
PX161201250000 | Risk Level Qualifier (Check One) | N/A | ||
PX161201_Working_Diagnosis_1 | ||||
PX161201300100 | Working Diagnosis 1 | N/A | ||
PX161201_Working_Diagnosis_1_Status | ||||
PX161201300200 | Working Diagnosis 1 Status (circle one) | N/A | ||
PX161201_Working_Diagnosis_2 | ||||
PX161201310100 | Working Diagnosis 2 | N/A | ||
PX161201_Working_Diagnosis_2_Status | ||||
PX161201310200 | Working Diagnosis 2 Status (circle one) | N/A | ||
PX161201_Working_Diagnosis_3 | ||||
PX161201320100 | Working Diagnosis 3 | N/A | ||
PX161201_Working_Diagnosis_3_Status | ||||
PX161201320200 | Working Diagnosis 3 Status (circle one) | N/A | ||
PX161201_Working_Diagnosis_4 | ||||
PX161201330100 | Working Diagnosis 4 | N/A | ||
PX161201_Working_Diagnosis_4_Status | ||||
PX161201330200 | Working Diagnosis 4 Status (circle one) | N/A | ||
PX161201_Working_Diagnosis_5 | ||||
PX161201340100 | Working Diagnosis 5 | N/A | ||
PX161201_Working_Diagnosis_5_Status | ||||
PX161201340200 | Working Diagnosis 5 Status (circle one) | N/A | ||
PX161201_Working_Diagnosis_6 | ||||
PX161201350100 | Working Diagnosis 6 | N/A | ||
PX161201_Working_Diagnosis_6_Status | ||||
PX161201350200 | Working Diagnosis 6 Status(circle one) | N/A |
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
Measure Protocols
Protocol ID | Protocol Name |
---|---|
161201 | International Travel History |
Publications
There are no publications listed for this protocol.