Elite Triathlete Travel Medical History Form
Personal Information
Full Name
Date of Birth
Gender
Male
Female
Other
Nationality
Passport Number
Emergency Contact Name
Emergency Contact Phone
Travel Details
Travel Destination(s)
Travel Dates
Medical History
Have you ever had (check all that apply):
Diabetes
Asthma
Heart Disease
Epilepsy/Seizures
Hypertension
Major Injuries
Other medical conditions
Current Medications
Allergies (medications/foods/insects)
Do you have any restrictions or require assistance?
Yes
No
If yes, please specify
Vaccination/Immunization History
COVID-19 Vaccination Status
Tetanus
Other Vaccinations (hepatitis, yellow fever, etc.)
Additional Information
Recent illness, hospitalization, or surgeries
Other relevant information