Pre-Travel Health Risk Assessment Checklist
Traveler Name
Date of Birth
Destination(s)
Travel Dates
Purpose of Travel
1. Medical History
Chronic diseases
Allergies
Immunocompromised
Pregnancy
Other
Details (if any):
2. Current Medications
List current medications:
3. Vaccination Status
Up-to-date on routine vaccines
Additional vaccines needed
Details (type/date):
4. Destination-Specific Risks
Malaria region
Yellow Fever
Zika Virus
Dengue
High Altitude
Other
Details/Precautions:
5. Special Considerations
Food and Water Safety
Personal Security
Transportation Risks
Other
Notes:
6. Emergency Contacts
Contact 1
Contact 2