Travel Health Medical History Form
Personal Information
Full Name
Date of Birth
Passport Number
Country of Residence
Emergency Contact
Phone Number
Travel Details
Destination(s)
Departure Date
Return Date
Purpose of Travel
Accommodation Details
Medical History
Do you have any chronic illnesses?
Yes
No
If yes, please specify
Do you have any allergies?
Yes
No
If yes, please specify
Are you currently taking any medications?
Yes
No
If yes, list medications
Immunization
Have you received the following vaccinations?
Yellow Fever
Typhoid
Hepatitis A
Hepatitis B
Tetanus
Rabies
Other
If other, please specify
Additional Information
Please provide any additional information relevant to your travel health