Special Needs and Accessibility Travel Health Form
Traveler Information
Full Name
Date of Birth
Contact Number
Email Address
Emergency Contact Name & Number
Accessibility Needs
Mobility Needs
Assistance Required (during travel/stays)
Assistive Devices (wheelchair, hearing aids, etc.)
Communication Preferences
Medical Details
Medical Conditions
Current Medication(s)
Allergies
Doctor’s Name & Contact
Additional Information
Dietary Restrictions
Other Needs / Notes