Microsoft word - travel history form.docx

Name: __________________________________________ Social Security No.: __________/________/____________ Address: __________________________________________________________________________________________ Date of Birth: _______/_______/________ Today’s Date: _______/_______/________ ☐ Male ☐ Female Home Telephone No.: (________) ________-___________ Cellular Phone: (________) ________-___________ E-Mail Address: __________________________________ Do you have a current passport or visa? ☐ Yes ☐ No What School? ________________________________________ ☐ Other ___________________________________________ What will you be doing on this trip?_____________________________________________________________________ __________________________________________________________________________________________________ Does your program require the completion of a medical form by a practitioner? Are you currently enrolled in a health insurance plan that covers you while overseas? What insurance coverage do you currently have? ________________________________________________________ Departure date from United States: ______/______/_______ Return date to United States: _______/_______/________ Countries AND cities to be visited in order of visits
Have you travelled outside the United States before? If yes, where and when? : _____________________________________________________________________ Visiting ONLY urban areas?
If no, explain: _______________________________________________________________________ Staying ONLY in Hotels?
If no, explain: _______________________________________________________________________ Ascending to high altitudes (>7,000 ft. or 2,300 meters) in the mountains? Working in the medical or dental field with exposure to blood or other body fluids? Potentially having sexual contact with new partners? Allergies 1. ☐ No known drug allergies 2. Have you had an allergic reaction to any of the following? (please check all that apply) ☐ Quinines (Chloroquine [Aralen], Mefloquine [Lariam], ☐ Sulfa Drugs (e.g. Bactrim, Septra) Hydroxychloroquine [Plaquenil], Primaquine) ☐ Antibiotics (e.g. Neomycin, Streptomycin) ☐ Thimerosal (preservative in contact lens solution) ☐ Chrysanthemums ☐ Tetracyclines (Doxycycline, Minocin, Minocyclin) ☐ Other: __________________________________________________________________________________ Immunizations 1. Were you born in the United States? If no, where? __________________________________ 2. Have you completed the following immunizations? when: #1____________#2___________ ☐ No ☐ Not Sure when: #1_______#2_______#3_______ ☐ No ☐ Not Sure when: ___________________________ ☐ No ☐ Not Sure when: ___________________________ ☐ No ☐ Not Sure when: ___________________________ ☐ No ☐ Not Sure when: ___________________________ ☐ No ☐ Not Sure when: ___________________________ ☐ No ☐ Not Sure when: ___________________________ ☐ No ☐ Not Sure what/when: ____________________________________________________ Medical History 1. Are you using steroids, receiving radiation or other immunosuppressive chemotherapy? 2. List your current prescription medications and medical condition treated: (include birth control pills) 3. List regularly used non-prescription medications (Over-the-counter, herbal, homeopathic, vitamins, etc.) Regularly Used Non-Prescription Medications 4. Have you been told you have any of the following medical conditions (check all that apply)? Other: ______________________________________________________________________________________________ 5. (For Women Only):
b. Are you, or could you possibly be pregnant? ☐ Yes ☐ No _________________________________ c. Are you breast-feeding an infant? Questions/Concerns 1. Please list additional questions or concerns you might have regarding your travel? (i.e. voltage requirements, currency conversion rates, etc.)____________________________________________________________________________ ______________________________________________________________________________________________

Source: http://www.christhealthcenter.org/pdfs/2014/travel_history_form.pdf