Section Menu Travel Medicine Clinic Intake Form Denotes required fields Your Information First Name Last Name Date of Birth Age Sex - Select -FemaleMale Address Address Address 2 City State? ZIP Code? Phone? Email How should we contact you? Phone Email Either Who is your primary care physician? Physician's telephone Employer Primary Insurance Does your insurance cover healthcare overseas? Yes No Not sure Does your insurance cover medical evacuation? Yes No Not sure Appointment time preferences Mornings, afternoons, suggested dates, etc. Travel Plans Purpose of Trip Check all that apply. Vacation Business Study Other… Enter other… Planned activities (list): Will you be: Visiting only urban areas? Yes No Don't know If no, please explain. Visiting family and/or friends? Yes No Don't know Ascending to high altitudes (8000 ft/2438 m or higher)? Yes No Don't know Working with potential exposure bodily fluids (e.g. medical or dental work)? Yes No Don't know Anticipating close exposure to animals? Yes No Don't know Potentially having new sexual partners? Yes No Don't know SCUBA diving? Yes No Don't know Going on a cruise ship? Yes No Don't know Do you have any medication or food allergies? Yes No Don't know If yes, list: Countries and Cities (in order of visits) + Arrival Date + Depart Date Accommodations Check all that apply. Resorts or Large Hotels Small Hotels Cruise Ship Private Home Camp Dormitory Youth Hostel Other… Enter other… Health History Were you born in USA? Yes No Positive TB skin test Yes No Heart Problems Yes No Seizure disorder Yes No History of tendon rupture Yes No Diabetes Yes No Blood clot disorder or ever had a DVT or PE Yes No Carry epinephrine, EpiPen, AuviQ Yes No Severe Headaches Yes No Pregnant/breastfeeding Yes No Sickle cell anemia Yes No Splenectomy Yes No Asthma Yes No Psychiatric disorder Yes No Any thymus disorders? Yes No Vaccination HistoryHave you received the following immunizations? Hepatitis A Yes No Not sure If yes, when? Hepatitis B Yes No Not sure If yes, when? HPV Yes No Not sure If yes, when? Influenza Yes No Not sure If yes, when? Japanese Encephalitis Yes No Not sure If yes, when? Meningococcal Meningitis Yes No Not sure If yes, when? Measles/Mumps/Rubella Yes No Not sure If yes, when? Pneumococcal Yes No Not sure If yes, when? Polio Yes No Not sure If yes, when? Tetanus Yes No Not sure If yes, when? Typhoid Yes No Not sure If yes, when? Varicella (Chicken pox) Yes No Not sure If yes, when? Yellow Fever Yes No Not sure If yes, when? Zoster (Shingles) Yes No Not sure If yes, when? RSV Yes No Not sure If yes, when? COVID-19 Yes No Not sure If yes, when? Haemophilus influenza (Hib) Yes No Not sure If yes, when? Have you received any other vaccines that were not listed? When? Have you ever had an adverse reaction to an immunization? Yes No Explain Medications Are you currently using corticosteroids, receiving cancer treatment, or other immunosuppressive therapy? Yes No Current Prescription Medications + Reason for Use/Medical Condition Non-Prescription Medications (Over-the-counter, herbals, vitamins, supplements, homeopathic products, etc.) + Reason for Use/Medical Condition List any additional questions or concerns you have about your travel: Leave this field blank
