Travel History Form

Please correct the errors described below.

TRAVEL PLANS:

Itinerary

List ALL Countries and ALL Cites in order of visit

Include ANY stopovers in Africa or South America

Countries and Cities

(list all)

Will you be:

Visiting areas that are:

Previous international travel:

Previous international travel

HEALTH HISTORY (Check all that apply):

Antibiotics

Other medications

Allergies

Side effects

HIV/AIDS
HIV/AIDS
weeks/trimester

VACCINATION HISTORY

Have you received the following immunizations?

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

QUESTIONS/CONCERNS

Your information will be encrypted.

Loading...