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Allergies
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Have you ever visited outside of United States
Yes
No
what countries?
When?
Purpose of Travel
Business
Pleasure
Visiting family or friends
Other
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Countries and cities are visiting:
Arrival Date:
Departure Date:
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Which one describes purpose of your travel the most?
Visiting only major cities
Staying in hotel all the time
Visiting rural areas
Travelling to high altitude >7000ft above see levels
Having contact with new sexual partners
Have you ever had any of these vaccines before?
Hepatitis A
Yes
No
Not sure
Date:
Hepatitis B
Yes
No
Not sure
Date:
Flu Vaccine
Yes
No
Not sure
Date:
Meningitis Vaccine
Yes
No
Not sure
Date:
MMR vaccine
Yes
No
Not sure
Date:
Tetanus-Diphteria-Pertusis
Yes
No
Not sure
Date:
Pneumonococal
Yes
No
Not sure
Date:
Thyphoid
Yes
No
Not sure
Date:
Rabies
Yes
No
Not sure
Date:
Japanese Encephalitis
Yes
No
Not sure
Date:
Shingles
Yes
No
Not sure
Date:
Please list all of your current medications:
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