Travel Clinic Questionnaire

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 State

Zip Code
E-mail
Phone Number *

Area Code Phone Number
Date of Birth *

Month Day Year
Gender *
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: *

Trip Purpose: check all that apply *

Business Vacation Study Missionary Visting Friends / Relatives Safari Cruise Extended Stay Volunteer or Humanitarian work
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
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
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
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

	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 Clear
Please verify that you are human *
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Travel Medical History Questionnaire