Pre-Travel Health Assessment Form
Full Name
Date of Birth
Gender
Female
Male
Other
Prefer not to say
Contact Number
Email Address
Intended Travel Destination(s)
Departure Date
Return Date
Do you have any chronic medical conditions?
Yes
No
If yes, please specify
Are you currently taking any medication?
Yes
No
If yes, list medication(s)
Do you have any drug allergies?
Yes
No
If yes, please specify
Have you received all recommended routine vaccinations?
Yes
No
If no, please specify vaccines not received
Other relevant information or concerns