Travel Allergy Risk Screening Sheet
Traveler Information
Name
Date of Birth
Contact Number
Email
Travel Details
Destination(s)
Departure Date
Return Date
Allergy History
Have you been diagnosed with any allergies?
Yes
No
If yes, please specify:
Food allergies
Medication allergies
Insect sting allergies
Other
Please list specific allergens:
Please describe your typical allergic reaction(s):
Do you carry emergency medication (e.g., EpiPen)?
Yes
No
Preparation for Travel
Do you have a travel medical plan for allergy emergencies?
Yes
No
Additional notes or concerns: