Travel Consultation
Self-Screening Patient Intake Form
Patient Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
Confirmation Email
example@example.com
Travel Specifics
Purpose of Trip
Activities
Departure Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Return Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Cities and countries to be visited (In order of visits)
*
Rows
City, Country to be visited
Arrival Date
Departure Date
Location 1
Location 2
Location 2
Location 3
Location 4
Location 5
Location 6
Have you traveled outside the United States before?
*
Yes
No
Please list where and when you traveled outside the U.S.
Travel Details
Rows
Answer
Explanation
Will you ONLY be using airplanes as your mode of transportation?
Yes
No
Unsure
Will you ONLY be visiting major cities?
Yes
No
Unsure
Will you ONLY be staying in hotels?
Yes
No
Unsure
Will you be visiting family and friends?
Yes
No
Unsure
Will you be ascending high altitudes? (>7,000 ft or 2,300 meters)
Yes
No
Unsure
Will you be working in the medical or dental field with exposure to blood or bodily fluids?
Yes
No
Unsure
Health Insurance Information
Do you have health insurance?
*
Yes
No
PLEASE BRING YOUR INSURANCE CARD TO YOUR APPOINTMENT!
Insurance Provider Name
*
Insurance ID or Policy Number
*
Health Care Provider Name
First Name
Last Name
Provider Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Provider Fax Number
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Health Information
Do you have any food allergies?
*
Yes
No
Please list your food allergies
Do you have any medication allergies?
*
Yes
No
Please list your medication allergies
Vaccination History
Vaccination
*
Rows
Dose 1
Dose 1 Date
Dose 2
Dose 2 Date
Covid
Yes
No
Yes
No
Hepatitis A
Yes
No
Yes
No
Hepatitis B
Yes
No
Yes
No
Influenza
Yes
No
Yes
No
Japanese Encephalitis
Yes
No
Yes
No
Meningococcal Meningitis
Yes
No
Yes
No
MMR (Measles, Mumps, Rubella)
Yes
No
Yes
No
Pneumonia
Yes
No
Yes
No
Polio (adult booster)
Yes
No
Yes
No
Rabies
Yes
No
Yes
No
Shingles
Yes
No
Yes
No
Tetanus (Tdap/TD/DTaP/DT)
Yes
No
Yes
No
Typhoid (Oral/Shot)
Yes
No
Yes
No
Varicella
Yes
No
Yes
No
Yellow Fever
Yes
No
Yes
No
Other
Yes
No
Yes
No
Other
Yes
No
Yes
No
Other
Yes
No
Yes
No
If you checked "Other" for vaccinations above, please specify which other vaccinations you have received.
If you received the Covid Vaccination, which manufacturer(s) did you recieve the vaccination from?
Pfizer
Moderna
Johnson & Johnson
Novavax
Please list any current medical conditions:
*
Please list your current prescription medications (include birth control and anti-depressants):
Please list any regularly used non-prescription medications (over the counter, herbal, homeopathic, vitamins, and supplements including those purchased at health-food stores):
Medical Questions
*
Rows
Yes
No
Unsure
Are you currently using steroids?
Are you currently receiving radiation therapy?
Are you currently receiving immunosuppressive therapy?
Are you pregnant or plan to become pregnant within the next year?
Are you currently breast-feeding?
Please list additional questions or concerns that you might have regarding your travel:
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Appointment
*
Submit
Should be Empty: