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Travel Health Assessment Form
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Travel Health Assessment Form

Contact Info

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Travel Info

  • Departure*
  • Return*

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  • Activities* (check all that apply)Medical/Dental ProcedureHigh-Altitude HikingClimbingSurfingDivingSnorkelingCampingJungle TourBusinessWork AbroadAgricultureStudyMissionary/Religious TripFamily VacationOther (please specify)

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  • Accommodations* (check all that apply)Medical FacilityUrbanHotel/MotelBed & BreakfastHostel/BackpackingRecreational VehicleStaying with Friends/RelationsRural/CountrysideFarmOther (please specify)

 

Healthcare Info

  • Date of Birth*

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  • Gender*FemaleMaleIntersexTransgender

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  • Medical Conditions* (check all that apply)Cancer (past/present)Suppressed Immune SystemHeart FailureHeart Valve DiseaseCOPDHigh Blood PressureArrhythmiaLiver DiseaseHistory of Blood ClotsHigh CholesterolDiabetesMigrainesDepressionAnxietyAcid RefluxNoneOther (please specify)

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  • Have you received blood products in the past year?*NoYes (please specify)

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  • Have you had any vaccinations/immunizations in the last 30 days?*NoYes (please specify)

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  • Have you had a reaction to a vaccine in the past?*NoYes (please specify)

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  • Do you use tobacco products?*NoYes

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  • Do you drink alcohol?*NoYes (please specify how many drinks per week)

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  • Do you use recreational drugs?*NoYes (please specify)

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  • Are you pregnant?*NoYes (please specify how far along)

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  • Are you considering becoming pregnant soon?*NoYes (please specify when)

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  • Are you breastfeeding?*NoYes

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