Travel Health Screening Questionnaire
Demographic Information:
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Travel Plans:
Purpose of Trip (Check all that apply):
*
Vacation
Business
Study
Other
Other: Describer below.
Planned Activities
*
Will you be visiting ONLY urban areas?
*
Yes
No
Will you be visiting friends and/or family?
*
Yes
No
Will you be traveling to high altitudes?
*
Yes
No
Will you be exposed to bodily fluids (including Medical and/or Dental work)?
*
Yes
No
Will you be working with/exposed to animals?
*
Yes
No
Will you potentially have new sex partners during your trip?
*
Yes
No
Please list Countries and Cities and Dates of Travel:
*
Accommodations (check all that apply):
*
Resort/Hotel
Cruise Ship
Private Home
Camp
Dormitory
Hostel
Other
Other: Describer below.
Health History:
Please list any Medical Conditions (ex. Heart Disease, stroke, cancer, diabetes, high blood pressure, depression, etc.):
*
Please list any Allergies, including medications, foods, or environmental allergens:
*
Are you pregnant now or is it possible you might become pregnant in the next 6 (six) months?
*
Yes
No
Not Applicable
Immunization History - Have you received the following immunizations? (Check all that apply)
*
COVID-19
Hepatitis A
Hepatitis B
Human Papilloma Virus (HPV)
Influenza
Japanese Encephalitis
Meningitis
Measles/Mumps/Rubella (MMR)
Pneumonia
Polio
Tetanus
Typhoid
Varicella
Yellow Fever
Zoster (Shingles)
Medications:
Are you using corticosteroids, receiving cancer treatment or immunosuppressive therapy?
*
Yes
No
Please list all medications (name, strength and directions) that you do not receive from Sebastopol Family Pharmacy:
Please list all non-prescription medications, herbals, vitamins and supplements that you take:
Questions:
Please list any questions or concerns you have about your travel:
Submit
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