Travel Health Assessment Form

Travel Health Assessment Form

Contact Info

 

Travel Info

  • Departure*
  • Return*
  •  

  •  

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

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

 

Healthcare Info

  • Date of Birth*
  •  

  • Gender*FemaleMaleIntersexTransgender
  •  

  • 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)
  •  

  •  

  •  

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

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

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

  • Do you use tobacco products?*NoYes
  •  

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

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

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

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

  • Are you breastfeeding?*NoYes
  •