Travel Questionnaire

Please complete the questionnaire below. This information will help us determine your immunization and other health-related needs. It will be sent securely to our e-mail and not shared with anyone else.

Date

Travelers Name (required)

Date of Birth

Phone #

Your Email (required)

Departure from US Date

Purpose of Travel

Destination
*if more than one, please include additional information in the comments section.

Date of arrival at destination

Departure date from destination

Length of stay at destination

Will you likely be exposed to blood and/or body fluids there?
 Yes No

Have you ever had a bad reaction/side effects from any vaccination?
 Yes No

Have you received immune globulin or any blood products in the past 8 months?
 Yes No

Do you have any medical condition that needs medication or physician follow up or one that may recur while traveling, such as high blood pressure, heart disease, diabetes, or lung problems?
 Yes No

Do you have a clotting disorder or low platelet count?
 Yes No

Have you ever had a seizure, convulsion, or epilepsy?
 Yes No

Have you ever had hepatitis or yellow jaundice?
 Yes No

Do you have any stomach problems?
 Yes No

Do you have cancer, HIV/AIDS, or any other immune disorder?
 Yes No

Do you have psoriasis?
 Yes No

Do you have any history of psychiatric/emotional problems or problems with strange dreams and/or nightmares?
 Yes No

Do you have a history of hives/urticaria?
 Yes No

Please list any allergies to food, medicine, or bee stings:

Please list your current medications:

Additional Comments:

For women only:
Are you pregnant?
 Yes No

Are you breastfeeding?
 Yes No

Your Message