Form Approved
OMB Control No.: 0920-XXXX
Expiration date: XX/XX/XXXX
Form 2: Medical Tourism Enhanced Surveillance Form
Instructions:
Health departments should use this form to collect additional information about an adverse health outcome associated with medical tourism when requested by the Centers for Disease Control and Prevention. The interviewer should complete the form by speaking directly with the patient when possible. Alternatively, interviewing someone familiar with the circumstances surrounding the adverse health outcome (e.g., medical provider, relative, friend) or medical chart abstraction is acceptable. The medical chart review may be done in consultation with the patient interview. Verbal consent should be obtained from patients, participation is voluntary. Please ensure any personally identifiable information is removed before uploading.
Case Investigation Form
Case ID (CDC to complete): ________________
Local Case ID (local health jurisdiction to complete): _________
State Case ID (state/territorial health jurisdiction to complete): ________
Patient Initials: ___________
Date form completed (MM/DD/YYYY): _______________________
If the interview was conducted in a language other than “English” please specify the name of the language here: ______________________
Date of interview (MM/DD/YYYY): ________
Who did you interview to complete this form? Select all that apply.
Patient
Friend or Family Member (specify relationship) ________
Healthcare provider
Medical chart review
Other (please specify): ________________
Name of person completing the form: ______________________________
Title: ___________________________________
Organization: ___________________________________
Contact phone number: ___________________________________
Contact email: ___________________________________________
If you are transferring data from an earlier interview, list the interviewers' names, contact number, and interview date for these interviews:
Interview A: Name: _________________ Tel: ________________ Date: / /
Interview B: Name: _________________ Tel: ________________ Date: / /
Interview C: Name: _________________ Tel: ________________ Date: / /
Patient interview/chart abstraction
Patient Underlying Medical Conditions
Please check any medical conditions you (the patient) had prior to traveling abroad. Select all that apply. For diseases with “describe” next to them specify the name of the disease and current treatment.
Autoimmune disease (describe: __________________________________________)
Cardiovascular disease (describe: _________________________________________)
Chronic respiratory disease (describe: _____________________________________)
Diabetes mellitus
Hepatic disease
HIV
Cancer (describe: ______________________________________________________)
Immune compromise (describe: __________________________________________)
Neurologic disease (describe: ____________________________________________)
Obesity
Renal disease
Other: ___________________________________
None
Surgery/treatment/procedure(s) received outside the United States
Background
Was your (the patient’s) surgery/treatment/procedure planned in advance?
Yes
No
Not sure/don’t know
Was a healthcare professional* in the United States informed of your (the patient’s) plans to receive the surgery/treatment/procedure outside the United States before departing from the United States? Select best answer.
*A healthcare professional is a physician, dentist, or other licensed medical professional that can evaluate and provide medical advice regarding traveling for medical care.
Yes, I (the patient) did consult a healthcare professional and was cleared to have the surgery/treatment/procedure
Yes, I (the patient) did consult a healthcare professional but was not cleared for the surgery/treatment/procedure. Why not cleared? _____________________
Yes, I (the patient) did consult a healthcare professional but no clearance evaluation for the surgery/treatment/procedure was done
No, I did not consult a healthcare professional
Prefer not to answer
Not sure/don’t know
Was having the surgery/treatment/procedure your (the patient’s) primary reason for traveling outside the United States? Select best answer.
Yes
No; the primary reason for traveling was: (select best answer)
Vacation
Missionary/humanitarian/volunteer/community service
Study abroad/educational purposes
Visiting friends or relatives
Lives outside of the United States
Work
Business
Research
Attended a conference
Seasonal or temporary work
Other (specify)________________
Prefer not to answer
Not sure/don’t know
Why did you (the patient) have the surgery/treatment/procedure performed outside the United States? Select all that apply.
I have a support system (e.g., family, friends) outside of the United States
It was included as part of a vacation package
I (the patient) was not approved to have the surgery/treatment/procedure in the United States
Medical emergency requiring immediate treatment (no time to return to the United States)
Surgery/treatment/procedure was not available in the United States
Too expensive in the United States
Not covered by U.S. health insurance
I (the patient) wanted the surgery/treatment/procedure to be performed by someone from my culture, or who speaks my language
Quality of medical care or chances of success are better in another country
I (the patient) live outside of the United States
Other (please explain) ________________________________________________
Prefer not to answer
Not sure/don’t know
What were the main reasons you selected this country to have the procedure? Select up to three.
Lower cost
Visited the country for a previous procedure
Have family and/or friends in the country
Previously resided in the country
Current resident of the country
Born in the country
Limited availability of procedure in other countries
Preferred clinic located there
Preferred healthcare professional located there
Recommendation from friend
Recommendation from social media
Referral from U.S. healthcare professional or insurance company
Other: _____________
How did you (the patient) learn about this clinician/doctor or healthcare facility? Select all that apply.
Advertisement (please specify source; select all that apply)
Magazine or newspaper: _________________________________
Online search: _________________________________________
Radio: ________________________________________________
Social media (ex. TikTok, Facebook, Instagram, Snapchat, etc.):__________
Social media influencer (ex. TikTok, Facebook, Instagram, Snapchat): _______________________________________________
Clinic or healthcare professional’s social media (ex. TikTok, Facebook, Instagram, Snapchat): _____________________________
Other social media (ex. TikTok, Facebook, Instagram, Snapchat): ___________________________________________
Television: ____________________________________________
Other: _______________________________________________
Company and/or individuals that connect U.S. clients with clinicians/healthcare facilities outside the United States (please provide the name of the company): _______________________________
Previous surgery, treatment, or procedure there
Referral from friend or relative
Other (please explain): ______________________________________
Prefer not to answer
Not sure/don’t know
Did you (the patient) look for information about the clinician/doctor or the healthcare facility before going there? If yes, what information did you research? Select all that apply.
Yes, about the clinician/doctor
Patient reviews
Price
Pictures of results posted by the clinician/doctor
Credentials/qualifications
Other: ________________________
Yes, about the healthcare facility/facilities.
Patient reviews
Price
Pictures of the healthcare facility/facilities
International accreditation
Other: ________________________
No research (skip to question 9)
Prefer not to answer (skip to question 9)
Not sure/don’t know (skip to question 9)
How did you do your research? Select all that apply.
Asking friends/family
Internet search
Social media
Other: _____________________
Post-Surgery/Treatment/Procedure(s)
Did you (the patient) stay in a recovery house, hotel, spa or another facility prior to travel back to the United States? How long were you there? Select all that apply.
Yes, I recovered in a facility (e.g., recovery house, hotel, spa) other than where the procedure was performed.
Facility name/address/ city/ country: ________________________________
Length of stay in days: ____________________
Yes, I stayed with friends or family
Length of stay in days:_______________
No, I recovered in the same facility where the procedure was performed. Length of stay in days: ____________________
No, I returned to the United States immediately (<24 hours) after the procedure
Prefer not to answer
Not sure/don’t know
While at the facility chosen for the surgery/treatment/procedure, did you (the patient) have any concerns about the clinic/surgical center or healthcare professional(s) that performed the procedure (?) If yes, what were your areas of concern?
Yes (select all that apply).
Cleanliness
Staff qualifications
Interaction with the staff (describe: ___________________________)
Other: ___________________
No
Prefer not to answer
Not sure/don’t know
Did you (the patient) receive instructions about what to expect after the surgery/treatment/procedure? If, yes what type of instructions did you receive?
Yes (select all that apply). (go to question 12)
Follow-up procedures (e.g., reminding the patient to check-in with a healthcare professional)
Medications
Infection prevention
Wound care
Other: __________________
No (go to question 14)
Prefer not to answer (go to question 14)
Not sure/don’t know (go to question 14)
How did you receive your instructions about what to expect after the surgery/treatment/procedure?
Verbal
Written (select all that apply).
Paper
Smart phone app
Website
Both written and verbal
Other: _______________
Were your (the patient’s) instructions communicated in a language you (the patient) understand fluently?
Yes
No
Not sure/don’t know
What signs and symptoms did you (the patient) experience after the surgery/treatment/procedure and how long after surgery did they start? Select all that apply. Note: the same day of the surgery is considered 0 days post-surgery.
Fatigue (days post-surgery: _____)
Fever (days post-surgery: _____)
Pain (days post-surgery: _____)
Bleeding or drainage from incision(s) or procedure site (days post-surgery: _____)
Redness around incision or procedure site (describe: __________) (days post-surgery: _____)
Respiratory symptoms (describe: _________) (days post-surgery: _____)
Swelling (days post-surgery: _____)
Other (describe: ________) (days post-surgery: _____)
Prefer not to answer
Not sure/don’t know
What type of complication(s) did you (the patient) experience after the surgery/treatment/procedure? Select all that apply. If using the electronic version of the form, indicate the organism identified from the list or select “other” and specify, if known. If using the paper form, enter the name of the organism in the space provided, if known. Please add additional details if necessary, in the space provided at the end of the form.
Infection
Bloodstream
Was an organism identified?
No
Not sure/don’t know
Yes, what organism(s) was identified? (specify:_____________)
Skin/soft tissue (e.g., cellulitis, abscess, wound infection)
Was an organism identified?
No
Not sure/don’t know
Yes, what organism(s) was identified? (specify:_____________)
CNS (e.g., meningitis, brain abscess)
Was an organism identified?
No
Not sure/don’t know
Yes, what organism(s) was identified? (specify:_____________)
Bone (i.e., osteomyelitis)
Was an organism identified?
No
Not sure/don’t know
Yes, what organism(s) was identified? (specify:_____________)
Wound at site of procedure
Was an organism identified?
No
Not sure/don’t know
Yes, what organism(s) was identified? (specify_____________)
Joint (i.e., septic arthritis)
Was an organism identified?
No
Not sure/don’t know
Yes, what organism(s) was identified? (specify_____________)
Urinary tract
Was an organism identified?
No
Not sure/don’t know
Yes, what organism(s) was identified? (specify:_____________)
Other infection-related diagnosis, specify_____________________
Was an organism identified?
No
Not sure/don’t know
Yes, what organism(s) was identified? (specify_____________)
Deep venous thrombosis
Pulmonary embolism
Death (describe): _____________________________________________
Other adverse health outcome (describe): _______________________
Did you (the patient) seek care after the surgery/treatment/procedure before returning to the United States?
No (go to question 21)
Prefer not to answer (go to question 21)
Not sure/don’t know (go to question 21)
Where did you (the patient) get the initial treatment before returning to the United States? Select all that apply.
At a clinic, urgent care center, or other outpatient setting
In a hospital (select all that apply).
Emergency department
Medical/surgical floor
Intensive care unit (ICU)
In a long-term care facility or rehabilitation center
Healthcare provider visited place of residence
Were you (the patient) admitted to a hospital after the surgery/treatment/procedure before returning to the United States?
Yes
No
Prefer not to answer
Not sure/don’t know
Please provide us with additional information about your (the patient’s) treatment location before returning to the United States.
If you (the patient) sought care at multiple facilities, enter the narrative (the date(s) visited, facility name, facility type, location, and please indicate whether it was affiliated with the original facility chosen for the surgery/treatment/procedure in the space at the end of Form 2). Can use medical records to complete this section if available.
Date(s): __________________________________
Facility name: __________________________________
Facility type
Location (Address if known, or city/state/country): ___________________________
What type of treatment did you (the patient) receive before returning to the United States? Select all that apply. Can use medical records to answer this question if available.
Antimicrobial medication
Blood product
Anticoagulant
Medical observation
Pain management
Surgery (describe): _____________________________
Wound care
Other (describe): _______________________________
Not sure/don’t know
Return to the United States
Did you (the patient) seek care in the United States for the complication/adverse health outcome?
Yes (go to question 22)
No, did not seek care (go to question 26)
Prefer not to answer (go to question 26)
Where did you (the patient) get the initial treatment after returning to the United States? Select all that apply.
At a clinic, urgent care center, or other outpatient setting
In a hospital (select all that apply).
Emergency department
Medical/surgical floor
Intensive care unit (ICU)
In a long-term care facility or rehabilitation center
Healthcare provider visited place of residence
Were you (the patient) admitted to a hospital after the surgery/treatment/procedure after returning to the United States?
Yes
No
Prefer not to answer
Not sure/don’t know
Please provide us with additional information about your (the patient’s) treatment location in the United States.
If you (the patient) sought care at multiple facilities, please provide the narrative (the date(s) visited, facility name, facility type, and location, in the space at the end of Form 2). Can use medical records to complete this section if available. If using the paper form, please add additional details as necessary in the space provided at the end of the form.
Date(s): __________________________________
Facility name: __________________________________
Facility type
Clinic, urgent care center or other outpatient setting
Hospital
Long-term care facility or rehabilitation center
Healthcare provider visited place of residence
Location (city/state): ___________________________
25. What type of treatment did you (the patient) get in the United States? Select all that apply. Can use medical records to answer this question if available.
Antimicrobial medication
Blood product
Anticoagulant
Medical observation
Pain management
Surgery (describe): _____________________________
Wound care
Other (describe): _______________________________
Not sure/don’t know
What is your (the patient’s) current health status related to the adverse health outcome?
Recovered
Hospitalized/receiving inpatient care
Resident of long-term care facility or subacute rehabilitation center receiving outpatient care
At private home, receiving outpatient care
Deceased
Date of death (MM/DD/YYYY):______
Please read to the interviewee: Below are questions about the costs related to receiving care abroad. This information will help us understand the financial burdens on medical tourists. If you do not feel comfortable answering these questions, feel free to skip this section and end the interview.
How did you (the patient) pay for the surgery/treatment/procedure done outside of the United States? Select all that apply.
Out-of-pocket
Private U.S. health insurance
Medicare
Supplemental health insurance for Medicare beneficiaries
Tricare
Other insurance (please specify source; select all that apply)
Travel health insurance
Medical evacuation insurance
National insurance, Country (please specify): __________________
Other (please specify):____________________________________
Prefer not to answer
Not sure / don’t know
If you (the patient) had a complication/adverse health outcome, how has care been paid for in the United States? Select all that apply.
Out-of-pocket
Private U.S. health insurance
Medicare
Supplemental health insurance for Medicare beneficiaries
Medicaid
Tricare
Other insurance (please specify source; select all that apply)
Travel health insurance
Medical evacuation insurance
National insurance, Country (please specify): ______________
Other (please specify): ______________________
Prefer not to answer
Not sure / don’t know
If you (the patient) used insurance to pay for a complication/adverse health outcome related to the surgery/treatment/procedure done outside of the United States, did you have a deductible and/or copay?
Yes
How much (in dollars): __________
No
Prefer not to answer
Not sure/ don’t know
Approximately how much did you (the patient) spend out of pocket on the surgery/treatment/procedure done outside of the United States? _________________
Approximately how much did you (the patient) spend out of pocket on other costs related to the surgery/treatment/procedure, including travel, lodging, food and other daily provisions? This does not include costs related to the complication/adverse health outcome. __________________
Approximately how much did you (the patient) spend out of pocket on treatment and recovery care (including care at a recovery center and/or home health care) for the complication/adverse health outcome related to the surgery/treatment/procedure done outside of the United States? _______________
Additional Notes/Additional Space for answers (if needed)
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Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS H21-8, Atlanta, GA 30333, ATTN: PRA (0920-XXXX).
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Stoney, Rhett (CDC/NCEZID/DGMH/THB) |
| File Modified | 0000-00-00 |
| File Created | 2025-07-24 |