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:
PLS Travel & Medical History Checklist
Patient’s Main Caregiver (1) Details
Name:

Relationship to Patient: Nationality:

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

Travel & Medical History

MERS-CoV
1) Has the caregiver 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 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?

Viral Hemorrhagic Fever (VHF)

1) Has the caregiver 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) 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

PLS Hotline: +65 6394 8888 Fax: +65 6292 5145 Email: pls@kkh.com.sg
78011-Form-0041 (30 June 2023)
 PLS Travel & Medical History Checklist
Name:

Relationship to Patient: Nationality:

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

Travel & Medical History

MERS-CoV
1) Has the caregiver 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 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?

Viral Hemorrhagic Fever (VHF)

1) Has the caregiver 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) 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)

PLS Hotline: +65 6394 8888 Fax: +65 6292 5145 Email: pls@kkh.com.sg
78011-Form-0041 (30 June 2023)
 PLS Travel & Medical History Checklist
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:

PLS Hotline: +65 6394 8888 Fax: +65 6292 5145 Email: pls@kkh.com.sg
78011-Form-0041 (30 June 2023)