Travel History Form

Name:

DOB:

Home Phone:

Work Phone:

Mobile Phone:

Home Address:

City:

State:

Zip:

Email:

Sex assigned at birth:

Male Female

Gender:

Pronouns:

TRAVEL PLANS:

Itinerary

Date leaving US:

Duration of Travel:

List ALL Countries and ALL Cites in order of visit

Include ANY stopovers in Africa or South America

Countries and Cities

Purpose of trip (check all that apply)

Vacation

Education/research

Adoption

Visit friends or family

Missionary/volunteer/humanitarian relief

Work

Other

Work:

Purpose of trip : Other

Planned activities:

(list all)

Will you be:

Visiting areas that are:

Rural:

Yes No Not Sure

Urban:

Yes No Not Sure

Primitive or remote:

Yes No Not Sure

Ascending to high altitudes (8,000 ft or higher)?

Yes No Not Sure

Working with potential exposure to body fluids (e.g., medical or dental work)?

Yes No Not Sure

Working with exposure to animals?

Yes No Not Sure

Potentially having new sexual partners?

Yes No Not Sure

Accommodations: (check all that apply)

Resort/large hotel

Small hotel/guest house/B&B

Cruise ship

Private home (with locals/relatives)

Private home (expatriate or high-end)

Primitive camping

Up-scale camp/lodge

Dormitory/ hostel

Other

Accommodations : Other

Previous international travel:

Previous international travel

HEALTH HISTORY (Check all that apply):

Cancers/blood disorder

Coagulation disorder

History of cancer or blood disorder

Other

Cancers/blood disorder : Other

Cardiovascular

Arrhythmia (rhythm disturbance considered significantly abnormal including atrial fibrillation, heart block)

Implanted pacemaker or automatic defibrillator

Heart attack

High cholesterol

High blood pressure

Stroke

Other

Cardiovascular : Other

Endocrine

Diabetes

Thyroid disease

Other

Endocrine : Other

Crohn’s disease or ulcerative colitis

IBS

GERD

Chronic hepatitis

Cirrhosis or liver failure

Other

GI : Other

Immune system

Steroids by mouth within last 3 months

Immune suppressive medications or treatments within last 3 months (e.g., radiation, cancer chemotherapy drugs, methotrexate, azathioprine, adalimumab, anakinra, etanercept, infliximab, leflunomide, rituximab)

Spleen removed

Thymus disease or thymectomy

HIV/AIDS

Organ, bone marrow, stem cell transplant

Other

Most recent CD4:

HIV/AIDS

Most recent viral load

HIV/AIDS

Organ, bone marrow, stem cell transplant

Immune system : Other

Kidneys

Dialysis

Kidney insufficiency

Other

Kidneys : Other

Lungs

Asthma

Emphysema/COPD

Other

Lungs : Other

Musculoskeletal

Psoriatic arthritis

Other

Musculoskeletal : Other

Neurologic/psychiatric

Seizures or epilepsy

Anxiety /depression

History of Guillain-Barré

Other

Neurologic/psychiatric : Other

Skin

Psoriasis

Other

Skin : Other

OB/GYN

Pregnant

Breastfeeding

Possible pregnancy in next 3 months

Other

Pregnant

weeks/trimester

OB/GYN : Other

VACCINATION HISTORY

Did you complete all routine/required childhood vaccines

Yes No Unknown

Have you received the following immunizations?

Hepatitis A

Yes No Not Sure

Hepatitis A : Yes, When?

Hepatitis B

Yes No Not Sure

Hepatitis B : Yes, When?

Meningococcal

Yes No Not Sure

Meningococcal : Yes, When?

Measles/Mumps/Rubella

Yes No Not Sure

Measles/Mumps/Rubella : Yes, When?

Polio

Yes No Not Sure

Polio : Yes, When?

Tetanus

Yes No Not Sure

Tetanus : Yes, When?

Typhoid

Yes No Not Sure

Typhoid : Yes, When?

Yellow Fever

Yes No Not Sure

Yellow Fever : Yes, When?

Japanese Encephalitis

Yes No Not Sure

Japanese Encephalitis : Yes, When?

Influenza

Yes No Not Sure

Influenza : Yes, When?

Other Vaccination

Other Vaccination : Which?

Other Vaccination : When?

Have you ever had an adverse reaction to an immunization?

Yes No

Please Explain:

CURRENT MEDICATIONS

Prescription medications: List all current prescription medications

Medication

WARNING - if you use any form of Cannabis, be advised it is illegal in many foreign countries and you could be detained

What Pharmacy do you use?

Location/Address of the Pharmacy

QUESTIONS/CONCERNS

Additional questions or concerns about your travel:

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