MediSav // Travel Vaccine Form

Step 1 of 5

20%

Name

First

Last

Date of Birth

MM slash DD slash YYYY

Marital Status

Sex

Telephone:

Home:

Work:

Mobile:

Home Address:

Street Address

Address Line 2

City

State

ZIP Code

Who is your primary care physician?

Telephone:

Employer:

Primary Insurance

Does your insurance cover:

Health care overseas?

Yes

Not sure

Medical evacuation?

Yes

Not sure

Travel Plans

Purpose of trip (check all that apply):

Vacation

Business

Study

Other

If other, explain

Planned activities:

Will you be:

Visiting ONLY urban areas?

Yes

If no, explain

Visiting friends and/or family?

Yes

Ascending to high altitudes?

Yes

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

Yes

Working with exposure to animals?

Yes

Potentially having new sexual partners?

Yes

Countries and Cities (in order of visits)

Countries and Cities (in order of visits)

Arrival Date

MM slash DD slash YYYY

Arrival Date

Departure Date

MM slash DD slash YYYY

Departure Date

Countries and Cities (in order of visits)

Arrival Date

MM slash DD slash YYYY

Arrival Date

Departure Date

MM slash DD slash YYYY

Departure Date

Countries and Cities (in order of visits)

Departure Date

MM slash DD slash YYYY

Arrival Date

MM slash DD slash YYYY

Departure Date

Countries and Cities (in order of visits)

Arrival Date

MM slash DD slash YYYY

Arrival Date

Departure Date

MM slash DD slash YYYY

Departure Date

Countries and Cities (in order of visits)

Departure Date

MM slash DD slash YYYY

Arrival Date

MM slash DD slash YYYY

Departure Date

Accommodations (check all that apply):

Resorts or Large Hotels

Small Hotels

Cruise Ship

Private Home

Camp

Dormitory

Youth Hostel

Other

If other, specify:

Have you traveled outside the United States before?

Yes

If yes, when and where?

Health History

Mental Conditions (such as heart disease, stroke, cancer, arthritis, diabetes, hypertension, psychiatric illnesses):

Surgical History:

Allergies (include medications, foods such as eggs, environmental allergens such as ragweed)

Intolerances or other reactions (include side effects from previous medications, such as nausea, constipation, sleepiness, dizziness, stomach upset, etc.):

Vaccination History

Were you born in the United States?

Yes

If no, where?

Have you received the following immunizations?

Hepatitis A

Yes

Not sure

If yes, when?

Hepatitis B

Yes

Not sure

If yes, when?

HPV

Yes

Not sure

If yes, when?

Influenza

Yes

Not sure

If yes, when?

Japanese Encephalitis

Yes

Not sure

If yes, when?

Meningococcal Meningitis

Yes

Not sure

If yes, when?

Measles/Mumps/Rubella

Yes

Not sure

If yes, when?

Pneumococcal

Yes

Not sure

If yes, when?

Polio

Yes

Not sure

If yes, when?

Tetanus

Yes

Not sure

If yes, when?

Typhoid

Yes

Not sure

If yes, when?

Varicella

Yes

Not sure

If yes, when?

Yellow Fever

Yes

Not sure

If yes, when?

Zoster (shingles)

Yes

Not sure

If yes, when?

Other

Have you ever had an adverse reaction to an immunization?

Yes

If yes, explain:

Medications

Are you currently using corticosteroids, receiving cancer treatment, or other immunosuppressive therapy?

Yes

Prescription Medications: List all current prescription medications and condition treated (include birth control pills):

Prescription Medications:

Reason for Use/Medical Condition

Nonprescription products: List all over-the-counter, herbal, homeopathic products, vitamins, supplements, etc.)

Nonprescription Medication

Reason for Use/Medical Condition

Women Only

Are you pregnant now, or do you suspect you might pregnant?

Yes

Do you have plans to become pregnant in the next 6 months?

Yes

Date of your last menstrual period:

Questions/Concerns:

List any additional questions or concerns you have about your travel:

Captcha