PLS Travel Checklist (Updated 9 Jan 2024)

For Official Use:
Date of TCU:
PLS Travel & Medical History Checklist
(Please complete the form and email to: pls@kkh.com.sg)
Medical Information Provided By

Name:
Relationship to Patient: Date:
Patient’s Details
Patient’s Name (as in passport):
HRN (Hospital Registration No.): Nationality:
Passport No.: Sex: F□ M□ Date of Birth:

Travel & Medical History
MERS-CoV
1) Has patient been to the following Middle East countries in the last 14 days? Yes □ No □ If yes, please elaborate.
(Jordan, Kuwait, Lebanon, Oman, Qatar, Saudi Arabia, United Arab Emirates (UAE), Yemen, _____________________________________
Bahrain, Iran, Iraq, Palestine, Syria)
2) Does patient have any of the following symptoms: ARI-Acute Respiratory Infection, fever, Yes □ No □ If yes, please elaborate.
cough, runny nose, sore throat and breathlessness in the last 14 days? _____________________________________
3) Did patient come into contact with any MERS-CoV case, exposure in healthcare facility or Yes □ No □ If yes, please elaborate.
contact with dromedary camels or consumption/exposure to their products in the Middle East _____________________________________
in the last 14 days?
Viral Hemorrhagic Fever (VHF)

1) Has patient been to the following countries in Africa in the last 21 days? Yes □ No □ If yes, please elaborate.
(Democratic Republic of Congo (DRC), Benin, Ghana, Guinea, Liberia, Mali, Nigeria, Sierra Leone, _____________________________________
Uganda)
2) Does patient have any of the following symptoms: Fever, vomiting, diarrhoea, headache, and Yes □ No □ If yes, please elaborate.
rash in the last 21 days? _____________________________________
3) Did patient come into contact with any Viral Hemorrhagic Fever (VHF) case in the last 21 Yes □ No □ If yes, please elaborate.
days? _____________________________________
Monkeypox
Is patient a suspect case of Monkeypox Yes □ No □ If yes, please elaborate.
_____________________________________
PLS Hotline: +65 6394 8888 Fax: +65 6292 5145 Email: pls@kkh.com.sg
78011-Form-0041 (30 June 2023)
For Official Use:
Date of TCU:
Patient’s Main Caregiver (1) Details
Name:
Relationship to Patient: Nationality:
Passport No.: Sex: F□ M□ Contact Number:

MERS-CoV
1) Has the caregiver been to the following Middle East countries in the last 14 days? Yes □ No □ If yes, please elaborate.
2) Does the caregiver have any of the following symptoms: ARI-Acute Respiratory Infection, Yes □ No □ If yes, please elaborate.
fever, cough, runny nose, sore throat and breathlessness in the last 14 days? _____________________________________
3) Did the caregiver come into contact with any MERS-CoV case, exposure in healthcare facility Yes □ No □ If yes, please elaborate.
or contact with dromedary camels or consumption/exposure to their products in the Middle _____________________________________
East in the last 14 days?

1) Has the caregiver been to the following countries in Africa in the last 21 days? Yes □ No □ If yes, please elaborate.
Uganda) Yes □ No □ If yes, please elaborate.
2) Does the caregiver have any of the following symptoms: Fever, vomiting, diarrhoea, _____________________________________
headache, and rash in the last 21 days? Yes □ No □ If yes, please elaborate.
3) Did the caregiver come into contact with any Viral Hemorrhagic Fever (VHF) case in the last _____________________________________
21 days?
Monkeypox
Is the caregiver a suspect case of Monkeypox Yes □ No □ If yes, please elaborate.
_____________________________________
Patient’s Main Caregiver (2) Details

78011-Form-0041 (30 June 2023)
Name:
Relationship to Patient: Nationality:
Passport No.: Sex: F□ M□ Contact Number:

MERS-CoV
1) Has the caregiver been to the following Middle East countries in the last 14 days? Yes □ No □ If yes, please elaborate.
2) Does the caregiver have any of the following symptoms: ARI-Acute Respiratory Infection, Yes □ No □ If yes, please elaborate.
fever, cough, runny nose, sore throat and breathlessness in the last 14 days? _____________________________________
3) Did the caregiver come into contact with any MERS-CoV case, exposure in healthcare facility Yes □ No □ If yes, please elaborate.
or contact with dromedary camels or consumption/exposure to their products in the Middle _____________________________________
East in the last 14 days?

1) Has the caregiver been to the following countries in Africa in the last 21 days? Yes □ No □ If yes, please elaborate.
Uganda) Yes □ No □ If yes, please elaborate.
2) Does the caregiver have any of the following symptoms: Fever, vomiting, diarrhoea, _____________________________________
headache, and rash in the last 21 days? Yes □ No □ If yes, please elaborate.
3) Did the caregiver come into contact with any Viral Hemorrhagic Fever (VHF) case in the last _____________________________________
21 days?
Monkeypox
Is the caregiver a suspect case of Monkeypox Yes □ No □ If yes, please elaborate.
_____________________________________
For Official Use:

To Be Filled In By PLS Staff (Upon receipt)
78011-Form-0041 (30 June 2023)
Verified By:
PLS Coordinator’s Name & Signature: Date/Time:
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
To Be Filled In By PLS Staff (On day of TCU):

Patient & Main caregiver’s Screening:
Name Temperature Travel History? Feeling Unwell? If yes, please elaborate.
Patient’s Name: Yes □ No □ Yes □ No □
___________ͦC
Main Caregiver Name: Yes □ No □ Yes □ No □
___________ͦC
Screened By:
PLS Coordinator’s Name & Signature: Date/Time:
78011-Form-0041 (30 June 2023)

PLS Travel Checklist (Updated 9 Jan 2024)

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PLS Travel Checklist (Updated 9 Jan 2024)

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Copyright:

Available Formats

For Official Use:

(Please complete the form and email to: pls@kkh.com.sg)

Medical Information Provided By

Relationship to Patient: Date:

HRN (Hospital Registration No.): Nationality:

Passport No.: Sex: F□ M□ Date of Birth:

Viral Hemorrhagic Fever (VHF)

Relationship to Patient: Nationality:

Passport No.: Sex: F□ M□ Contact Number:

Travel & Medical History

Viral Hemorrhagic Fever (VHF)

Patient’s Main Caregiver (2) Details

Relationship to Patient: Nationality:

Passport No.: Sex: F□ M□ Contact Number:

Travel & Medical History

Viral Hemorrhagic Fever (VHF)

For Official Use:

To Be Filled In By PLS Staff (On day of TCU):

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