Travel Medical History Questionnaire
Thank you for your interest in our Travel Clinic services. Please complete the questionnaire for each person traveling in your party. The fee for the travel consultation is $60 / per person. Our Travel Pharmacist will conduct a full review of your travel itinerary, your medical and immunization history along with vaccination recommendations to help ensure a safe and healthy trip.
Patient Information:
Full Name
*
First Name
Last Name
Home Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
E-mail
Phone Number
*
-
Area Code
Phone Number
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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Day
Please select a year
2024
2023
2022
2021
2020
2019
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2015
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2012
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1921
1920
Year
Gender
*
Male
Female
Weight (if under 18 years old)
Travel Itinerary:
Have you previously traveled to a developing country?
*
Yes
No
Are you traveling alone?
*
Yes
No
If No, name and age of other travelers:
Departure Date:
-
Month
-
Day
Year
Date
Return Date:
-
Month
-
Day
Year
Date
Please list, in order, all specific cities and countries including plane transfers and layovers:
Please list, in order, all specific cities and countries including plane transfers and layovers:
*
Arrival
Date
City
Country
Departure
Date
Destination 1
Destination 2
Destination 3
Destination 4
Destination 5
Destination 6
Destination 7
Destination 8
Destination 9
Destination 10
Destination 11
Destination 12
Trip Purpose: check all that apply
*
Business
Vacation
Study
Missionary
Visting Friends / Relatives
Safari
Cruise
Extended Stay
Volunteer or Humanitarian work
Other
Accommodations: check all that apply
*
Hotel 4 or 5 star
Hotel 2 or 3 star
Hostel
Private Home
Camping
Safari
Staying with locals
Extended Stay Apartment
Cruise Ship
Other
Trip Activities: check all that apply
*
Air Travel
Public Transportation (Bus, Train, etc)
Biking
Rental Car
Water Sports (Swimming, boating, etc)
Scuba or Snorkeling
Climbing or Hiking
Visiting schools, hospitals, orphanages
Health care worker
Contact with animals
Other
Allergies:
Please identify any allergies
*
Yes
No
Which Ones?
Medication Allergy?
Environmental Allergy (ie hayfever, bee stings)?
Have you had an adverse reaction to an anti-malarial medicine?
Other allergies?
Women Only:
Date of Last Period
-
Month
-
Day
Year
Date
Are you Pregnant?
*
Yes
No
If "Yes", what is your due date?
Are you able to become pregnant?
*
Yes
No
If "No", please describe why you are not able to become pregnant
What is your method of birth control?
Barrier Methods
IUD
Oral Contraceptive
Abstinence
N/A
Other
Immunization History:
Do you have a written record of your vaccinations?
*
Yes
No
If you have your Immunization record you can upload an image of it here:
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Have you had any serious reactions to any vaccines?
*
Yes
No
If "Yes", please describe reaction and to which vaccine.
Have you been vaccinated in the past 4 weeks?
*
Yes
No
If Yes, which vaccines have you received in the past 4 weeks?
Vaccination History
Dates Received
Never Had
Not Sure
Had Disease
Comments
COVID-19
Tetanus-Diphtheria or Tdap
Measles, Mumps, Rubella (2 doses)
Polio (childhood series)
Polio (adult booster)
Chicken pox or Varicella (2 doses)
Meningitis (Menomune or Menactra)
Pneumonia
Influenza (flu)
Hepatitis A (2 doses)
Hepatitis B (3 doses)
Typhoid (□ oral or □ injectable)
Yellow Fever
Japanese Encephalitis (2 doses)
Rabies (3 doses)
Other Vaccines:
Medical History:
Medical History
Yes
No
If Yes, please provide details
Psychiatric Problems
Irregular Heartbeat
Psoriasis
Respiratory Problems
Seizures
Heart Disease or surgery
Immunity Problems
Immune Suppression Drugs
Surgeries
Other:
Please list all current medications and reason for use. (Include prescription, over-the-counter, supplements, eye drops, etc)
Insurance Information:
Insurance Provider
Please include a picture of the front of your prescription insurance card
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Please include a picture of the back of your prescription insurance card
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Consent:
How did you hear about our travel clinic service?
*
The above information is complete and accurate to the best of my knowledge. I hereby consent to consultation and treatment / administration of vaccines.
*
Traveler / Parent / Guardian Signature
Please verify that you are human
*
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