Child Travel Health Assessment Questionnaire

Child Travel Health Assessment Questionnaire

Please complete this questionnaire so a pediatrician can review your child's travel health information before issuing any Fit-to-Fly certificate.
Parent / Guardian Information
Parent / Guardian Full Name

First NameMiddle NameLast Name
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Child
Child Information
Child's Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Age
Country of Residence
Travel Information
Departure country
Destination country
Departure Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Flight Duration (if known)
Flight Number (if known)
The airline you fly with
Reason for Requesting Assessment

Other
Current Health Status
Does the child currently have any symptoms?
If yes, please describe the symptoms
Has the child had a fever in the last 14 days?
Highest temperature
Date of fever

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Cause of fever, if known
Recent Illness
Has the child been diagnosed with any illness recently?
Please provide details of the recent illness
Has the child taken any medication recently?
Please provide details of the recent medication
Ear, Nose and Flight-related Questions
Has the child had ear pain or an ear infection recently?
Has the child experienced any problems during previous flights?
If yes, please describe the flight-related problems.
Medical History
Does the child have any chronic medical conditions?
If yes, please provide details
Current medications
Known allergies
Consent
Confirmation of Information Accuracy
Acknowledgment of Assessment Outcome
Should be Empty:

Child Travel Health Assessment Questionnaire

Parent / Guardian Information

Child Information

Travel Information

Current Health Status

Recent Illness

Ear, Nose and Flight-related Questions

Medical History

Consent