Travel Vaccine Screening Form

Travel Consult Screening Form
Name
Date of birth
Gender
Address

Home address

Street Address Line 2

CityState / Province

Zip Code
Telephone
Format: (000) 000-0000.
Race/Ethnicity
Please indicate which of the following vaccines you have received:

InfluenzaShinglesPneumoniaTetanusHepatitis A/BMMRYellow FeverPolioVaricellaRabiesTyphoidMeningococcalCovid-19
Do you have any chronic medical conditions? If yes, please specify:
Are you currently pregnant or breastfeeding? If yes, please specify:
Do you have any allergies, including drug allergies? If yes, please specify:
Are you currently taking any medications? If yes, please specify:
Do you have a history of liver disease (cirrhosis or hepatitis)? If yes, please specify:
Do you have any history of kidney disease (or renal impairment)? If yes, please specify:
Are you currently taking any antibiotics? If yes, please specify:
Are you immunocompromised or on immunosuppressive therapy? If yes, please specify:
Travel destination (Specific Locations)
Departure Date

MonthDayYear
Date
Return Date

MonthDayYear
Date
Please indicate which of the following vaccines or prophylaxis you are seeking today:

MMRYellow FeverPolioVaricellaRabiesTyphoidMeningococcalHepatitis A/BMalaria ProphylaxisTraveler's DiarrheaMotion Sickness/NauseaAltitude SicknessOther
I acknowledge that I have provided accurate information about my health and medications. I understand the potential contraindications or precautions regarding the travel medications prescribed, and I will follow the healthcare provider's recommendations for alternative treatments or medications as necessary.
Date

MonthDayYear
Date
Should be Empty:

Travel Consult Screening Form