Fill in form online, then print and bring to appointment.

CURRENT HEALTH
Name of personal health care provider
 Phone number
Address, City, Zip
Do you have any allergies? Yes No    If yes, please list and describe type of reactions below
Medications
 Bee or wasp sting
Environmental
 Food (especially eggs)
Male Female If female, are you currently pregnant?
Yes No
MEDICAL HISTORY
Please check all applicable conditions below and explain in area provided, if necessary.
Indicate date of your last visit to a clinician for each condition.
skin disease, eczema heart problem
hay fever jaundice/liver disease
back problem lung disease
emotional/mental problems cancer
seizure disorder diabetes
digestive tract problem blood disorder
headaches (frequent/severe) urinary tract problem
high blood pressure recent surgery
recent hospitalization immune deficiency disorder
Please explain all conditions checked above

Number

Name

DOB

MEDICATIONS
Please list all medications you take regularly.
Include vitamins, non-prescription medications, oral contraceptives.
prescription medication

 non-prescription medication
oral contraceptive

 other (specify)


PREVIOUS IMMUNIZATIONS
Please list dates for those immunizations you have received. BRING ALL RECORDS
Tetanus/diphteria Yellow Fever
Measles Japanese encephalitis
Mumps Influenza
German Measles (Rubella) Pneumovax
Polio - OPV/IPV Rabies
Typhoid Hepatitis A
Varivax/Chicken Pox Meningococcal
Hepatitis B Twinrix
Tetanus/diptheria/pertussis HPV vaccine
Others (specify)
Have you ever received a tuberculosis (PPD) skin test? Yes No
If yes, date(s) of test
positive negative
Have you ever been treated for tuberculosis? Yes No


LOCAL CONTACT
In case of emergency or illness
Name
Relationship
Address
 Phone Number


TRAVEL PLAN
Departure date
 Return date


ANTICIPATED TRAVEL CONDITIONS
Check all that apply
organized group travel first class hotel
independent travel university dormitory/youth hostel
camping private home
working in contact with animals/insects &/or doing field work (specify)
other (specify)


ITINERARY
Please list countries you plan to visit in chronological order with an estimated duration of stay in each country. Star[*] any countries in which you plan to camp or stay outside major urban areas
Country



 Estimated duration



 Country



 Estimated duration
Please describe any special problems you anticipate while travelling, or health concerns you wish to discuss with the clinician.
Have you travelled previously to developing countries? Yes No
If yes, where and when?
Have you taken antimalarial medicine in the past? Yes No
If yes, which one?