Travel Health Assessment Form

Pre-Travel Health Consultation and History Form

TRAVELER INFORMATION

Traveler's Name:

Date of birth:

MaleFemale

Street address:

Telephone
Home:
Work:
Cell:

Email address:

Country of birth:
Citizenship:

TRIP INFORMATION

Date of departure from home:
Return date/length of trip:
Have you traveled internationally in the past? YesNo
If yes, where?

Itinerary: Please give ALL countries to be visited, including stopovers, in the order (if possible) to be visited:

Destination: UrbanRuralRemoteAt High AltitudeBeach

Is this a fixed itinerary? YesNoUnsure

Purpose of trip: (check all that apply)
VacationMedical CareBusinessEducationAdoptionVolunteer/HumanitarianVisiting Friends and/or RelativesLong-stay traveler

Organized tour? YesNoPartly
Explain:

Accommodations: HotelHostelStaying with locals/family/friendsRented House/AptCampingCruise Ship/Boat

PLANNED ACTIVITIES

(check all that apply)
Air TravelBikingHikingSnorkelingSwimmingRaftingBoatingScubaClimbing/Trekking
Contact with animalsCave/spelunkingPublic transportation (bus, train, etc.)Visiting schools, hospitals or orphanages
Health care workerOccupational exposure
Other:

Have you obtained travel medical evacuation insurance? YesNo

HEALTH HISTORY

Physician's name:
Physician's address:
Physician's telephone:

Do you have any chronic health problems for which you take medication on a regular basis or see a physician? YesNo
If yes, please explain:

Are you currently under the care of a physician for any health problem? YesNo
If yes, please explain:

Do you currently have or have a past history of:
Antidepressant or psychiatric medication use YesNo
Depression, anxiety, panic attacks YesNo
Psoriasis (skin disease) YesNo
Seizures or convulsions YesNo
Cardiac conduction defect, have a pacemaker YesNo
Heart disease or surgery YesNo
Respiratory (lung) disease YesNo
Muscle or bone problems YesNo
Intestinal problems including heartburn or reflux YesNo
Immune disorder (chemotherapy, HIV, bone marrow or organ transplant,
rheumatoid arthritis treatment) YesNo
Thymus gland surgery or disorder (myasthenia gravis, DiGeorge syndrome) YesNo
History of altitude illness YesNo
Surgery or hospitalization in past 3-5 years YesNo
Have you had any transfusions or blood products in the past 5 years? YesNo
Have you ever had Hepatitis (liver infection)? YesNo
Has your spleen been removed? YesNo
Do you drink alcohol regularly? YesNo
Do you smoke? YesNo
Have you ever had a TB test? YesNo
History of tendonitis / Achilles’ heel rupture YesNo
Have you ever had a convulsion, seizure,epilepsy or neurologic condition? YesNo
Other medical problem YesNo
Please explain any “yes” answers:

Allergies:
Medication(s) YesNo -- If yes, list:
Reaction to vaccine YesNo -- If yes, list:
Egg or other food allergies YesNo -- If yes, list:
Environmental (pollens, dust, hay fever, etc.) YesNo -- If yes, list:
Animals YesNo -- If yes, list:
Bee stings YesNo
Have you ever experienced anaphylaxis (severe allergic reaction)? YesNo
If “Yes” please describe:

Medications:
Please list all prescribed and over-the-counter medications and supplements you use:
1. Medication or supplement: -- Reason for use:
2. Medication or supplement: -- Reason for use:
3. Medication or supplement: -- Reason for use:
4. Medication or supplement: -- Reason for use:
5. Medication or supplement: -- Reason for use:
6. Medication or supplement: -- Reason for use:
7. Medication or supplement: -- Reason for use:
8. Medication or supplement: -- Reason for use:
9. Medication or supplement: -- Reason for use:
10. Medication or supplement: -- Reason for use:

IMMUNIZATION HISTORY

Tetanus-Diptheria Vaccine or Tdap YesNoUnsureHad the disease -- Date immunized:
Measles Mumps Rubella (2 doses) YesNoUnsureHad the disease -- Date immunized:
Typhoid, injectable or oral YesNoUnsureHad the disease -- Date immunized:
Influenza YesNoUnsureHad the disease -- Date immunized:
Hepatitis A – 1st dose YesNoUnsureHad the disease -- Date immunized:
Hepatitis A – 2nd dose YesNoUnsureHad the disease -- Date immunized:
Hepatitis B – 1st dose YesNoUnsureHad the disease -- Date immunized:
Hepatitis B – 2nd dose YesNoUnsureHad the disease -- Date immunized:
Hepatitis B – 3rd dose YesNoUnsureHad the disease -- Date immunized:
Polio -- childhood series YesNoUnsureHad the disease -- Date immunized:
Polio -- adult dose or booster YesNoUnsureHad the disease -- Date immunized:
Chicken pox-varicella (2 doses) YesNoUnsureHad the disease -- Date immunized:
Meningitis (Menomune or Menactra) YesNoUnsureHad the disease -- Date immunized:
Rabies (3 doses) YesNoUnsureHad the disease -- Date immunized:
Japanese Encephalitis (3 doses) YesNoUnsureHad the disease -- Date immunized:
Yellow Fever YesNoUnsureHad the disease -- Date immunized:
Pneumococcal YesNoUnsureHad the disease -- Date immunized:
Other vaccines—please list:

Women:
Are you currently or are you trying to become pregnant? YesNo
Any risk of an unplanned pregnancy? YesNo
Are you breastfeeding? YesNo
What form of contraception do you use?

Other:
Please tell us any additional information that you believe is important for us to know as you prepare for your trip:

I have answered this questionnaire fully and to the best of my ability.

Traveler’s signature (type full name): -- Relationship if minor:

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