Senior Traveler Health Assessment
Personal Information
Full Name
Date of Birth
Gender
Female
Male
Other
Prefer not to say
Travel Details
Destination(s)
Travel Dates
Type of Travel
Leisure
Business
Family Visit
Other
Medical History
Chronic Illnesses (e.g., diabetes, heart disease)
Current Medications
Allergies
Past Surgeries or Hospitalizations
Functional Assessment
Mobility Issues
Assistive Devices Used
Immunizations & Preventive Care
Vaccinations (e.g., flu, COVID-19, yellow fever)
Recent Health Checks
Emergency Contact
Contact Name
Relationship
Phone Number
Additional Notes