Travel Medicine

Travel Vaccination Questionnaire

Note: This form should only be used for international travel

Name *
Sex *
Date of Birth *
Phone *
Email *
Your Destination (countries/cities) *
Dates of Trip *
Purpose of your Trip *
Are you currently treated for any medical problems *
Have you had a significant medical problem in the past *
Could you be pregnant *
Are you staying mostly in cities / tourist destinations *
Are you going to spend time above 5000 ft *
Are you going to work in the foreign country *
Are you allergic to eggs or chicken products *
Have you had any hypersensitivity or reaction to vaccinations *
Have you had Guillain-Barre Syndrome
Have you had all of your childhood vaccinations
Have you had tetanus/diphtheria vaccination in the last 10 years
Have you had measles vaccination (2 shots)
Have you had polio vaccination as an adult
Have you had hepatitis A vaccination (2 shots)
Have you had hepatitis B vaccination (3 shots)
Have you had meningitis vaccination in the past 3 years *
Have you had typhoid vaccination in the past 2 years (if injected), or in the past 5 years (if oral) *
Have you had yellow fever vaccination in the past 10 years *
Have you had Japanese encephalitis vaccination in the past 2 years *
List current or previous significant medical conditions *
List current medications *
List allergies *
Comments *

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