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Travel Vaccine Form
Step
1
of
5
20%
Name
First
Last
Date of Birth
Marital Status
Sex
M
F
Telephone:
Home:
Work:
Mobile:
Home Address:
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Email
Who is your primary care physician?
Telephone:
Employer:
Primary Insurance
Does your insurance cover:
Health care overseas?
Yes
No
Not sure
Medical evacuation?
Yes
No
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
No
If no, explain
Visiting friends and/or family?
Yes
No
Ascending to high altitudes?
Yes
No
Working with potential exposure to bodily fluids (e.g., medical or dental work)?
Yes
No
Working with exposure to animals?
Yes
No
Potentially having new sexual partners?
Yes
No
Countries and Cities (in order of visits)
Countries and Cities (in order of visits)
Arrival Date
Arrival Date
Departure Date
Departure Date
Countries and Cities (in order of visits)
Arrival Date
Arrival Date
Departure Date
Departure Date
Countries and Cities (in order of visits)
Departure Date
Arrival Date
Arrival Date
Departure Date
Countries and Cities (in order of visits)
Arrival Date
Arrival Date
Departure Date
Departure Date
Countries and Cities (in order of visits)
Departure Date
Arrival Date
Arrival Date
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
No
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
No
If no, where?
Have you received the following immunizations?
Hepatitis A
Yes
No
Not sure
If yes, when?
Hepatitis B
Yes
No
Not sure
If yes, when?
HPV
Yes
No
Not sure
If yes, when?
Influenza
Yes
No
Not sure
If yes, when?
Japanese Encephalitis
Yes
No
Not sure
If yes, when?
Meningococcal Meningitis
Yes
No
Not sure
If yes, when?
Measles/Mumps/Rubella
Yes
No
Not sure
If yes, when?
Pneumococcal
Yes
No
Not sure
If yes, when?
Polio
Yes
No
Not sure
If yes, when?
Tetanus
Yes
No
Not sure
If yes, when?
Typhoid
Yes
No
Not sure
If yes, when?
Varicella
Yes
No
Not sure
If yes, when?
Yellow Fever
Yes
No
Not sure
If yes, when?
Zoster (shingles)
Yes
No
Not sure
If yes, when?
Other
Have you ever had an adverse reaction to an immunization?
Yes
No
If yes, explain:
Medications
Are you currently using corticosteroids, receiving cancer treatment, or other immunosuppressive therapy?
Yes
No
Prescription Medications: List all current prescription medications and condition treated (include birth control pills):
Prescription Medications:
Add
Remove
Reason for Use/Medical Condition
Add
Remove
Nonprescription products: List all over-the-counter, herbal, homeopathic products, vitamins, supplements, etc.)
Nonprescription Medication
Add
Remove
Reason for Use/Medical Condition
Add
Remove
Women Only
Are you pregnant now, or do you suspect you might pregnant?
Yes
No
Do you have plans to become pregnant in the next 6 months?
Yes
No
Date of your last menstrual period:
Questions/Concerns:
List any additional questions or concerns you have about your travel: