TRAVELER HISTORY FORM

Complete this form and bring all immunization records to your clinic appointment.

Personal Information

* First Name

* Last Name

* Date of Birth

* Sex

Home Phone#

Work Phone#

Mobile Phone#

* Home Address

City

State

Zip

Your Email

Primary Care Physician

Physician Phone#

Do You Currently Have Insurance

Travel Plans

Purpose of Trip (check all that apply)

Other

Planned Activities (list all):

Will You Be:

Visiting Rural Areas?

Visiting Urban Areas?

Visiting Primitive or Remote Areas?

Ascending to high altitudes (8,000 ft or higher)?

Working with potential exposure to body fluids (e.g., medical or dental work)?

Working with exposure to animals?

Potentially having new sexual partners?

Accommodations (check all that apply)

Other

Previous international travel (year/destination):

Countries and Cities In Order of Visit (FOR CURRENT TRIP)

Country and City

Arrival
Date

Departure
Date

Health History

(Check all that apply)

Vaccination History

(Please bring all vaccination records to your appointment.)

Have you received the following immunizations?

Hepatitis A

Hepatitis B

Meningococcal

Measles/Mumps/Rubella

Polio

Tetanus (Td)

Tetanus (Tdap)

Typhoid

Yellow Fever

Japanese Encephalitis

Influenza

Other

Have you ever had an adverse reaction to an immunization?

Current Medications

Prescription Medications: List all current prescription medications

Medication

Reason for use/medical condition

Non-Prescription Products: List current over-the-counter, herbal, homeopathic products, vitamins, supplements, etc.

Product

Reason for use/medical condition

TRAVELER HISTORY FORM

Complete this form and bring all immunization records to your clinic appointment.

Personal Information

Travel Plans

Purpose of Trip (check all that apply)

Will You Be:

Accommodations (check all that apply)

Countries and Cities In Order of Visit (FOR CURRENT TRIP)

Health History

(Check all that apply)

Allergies (check all that apply) [ Hide This Group ]

Cancers/Blood Disorders (check all that apply) [ Hide This Group ]

Cardiovascular (check all that apply) [ Hide This Group ]

Endocrine (check all that apply) [ Hide This Group ]

GI (check all that apply) [ Hide This Group ]

Immune System (check all that apply) [ Hide This Group ]

Kidneys (check all that apply) [ Hide This Group ]

Lungs (check all that apply) [ Hide This Group ]

Musculoskeletal (check all that apply) [ Hide This Group ]

Neurologic/Psychiatric (check all that apply) [ Hide This Group ]

Skin (check all that apply) [ Hide This Group ]

OB/GYN (check all that apply) [ Hide This Group ]

Vaccination History

(Please bring all vaccination records to your appointment.)

Have you received the following immunizations?

Current Medications

Prescription Medications: List all current prescription medications

Non-Prescription Products: List current over-the-counter, herbal, homeopathic products, vitamins, supplements, etc.

Questions/Concerns

Additional questions or concerns about your travel:

TRAVELER HISTORY FORM

Complete this form and bring all immunization records to your clinic appointment.

Personal Information

Travel Plans

Purpose of Trip (check all that apply)

Will You Be:

Accommodations (check all that apply)

Countries and Cities In Order of Visit (FOR CURRENT TRIP)

Health History

(Check all that apply)

Allergies (check all that apply) [ Hide This Group ]

Cancers/Blood Disorders (check all that apply) [ Hide This Group ]

Cardiovascular (check all that apply) [ Hide This Group ]

Endocrine (check all that apply) [ Hide This Group ]

GI (check all that apply) [ Hide This Group ]

Immune System (check all that apply) [ Hide This Group ]

Kidneys (check all that apply) [ Hide This Group ]

Lungs (check all that apply) [ Hide This Group ]

Musculoskeletal (check all that apply) [ Hide This Group ]

Neurologic/Psychiatric (check all that apply) [ Hide This Group ]

Skin (check all that apply) [ Hide This Group ]

OB/GYN (check all that apply) [ Hide This Group ]

Vaccination History

(Please bring all vaccination records to your appointment.)

Have you received the following immunizations?

Current Medications

Prescription Medications: List all current prescription medications

Non-Prescription Products: List current over-the-counter, herbal, homeopathic products, vitamins, supplements, etc.

Questions/Concerns

Additional questions or concerns about your travel:

Traveler History Form Status