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)

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 ]

HIV/AIDS

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 ]

Pregnant

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: