Travel Health Assessment Form

Please complete this form prior to your Travel Clinic appointment. This will ensure that one of our pharmacists will have all the necessary information to provide you with a thorough assessment. All information will be held in confidence.

Required fields are marked with an *

    Contact Info

     

    Travel Info

    • Departure*
    • Return*
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    • Activities* (check all that apply)Medical/Dental ProcedureHigh-Altitude HikingClimbingSurfingDivingSnorkelingCampingJungle TourBusinessWork AbroadAgricultureStudyMissionary/Religious TripFamily VacationOther (please specify)
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    • Accommodations* (check all that apply)Medical FacilityUrbanHotel/MotelBed & BreakfastHostel/BackpackingRecreational VehicleStaying with Friends/RelationsRural/CountrysideFarmOther (please specify)

     

    Healthcare Info

    • Date of Birth*
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    • Gender*FemaleMaleIntersexTransgender
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    • Medical Conditions* (check all that apply)Cancer (past/present)Suppressed Immune SystemHeart FailureHeart Valve DiseaseCOPDHigh Blood PressureArrhythmiaLiver DiseaseHistory of Blood ClotsHigh CholesterolDiabetesMigrainesDepressionAnxietyAcid RefluxNoneOther (please specify)
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    • Have you received blood products in the past year?*NoYes (please specify)
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    • Have you had any vaccinations/immunizations in the last 30 days?*NoYes (please specify)
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    • Have you had a reaction to a vaccine in the past?*NoYes (please specify)
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    • Do you use tobacco products?*NoYes
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    • Do you drink alcohol?*NoYes (please specify how many drinks per week)
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    • Do you use recreational drugs?*NoYes (please specify)
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    • Are you pregnant?*NoYes (please specify how far along)
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    • Are you considering becoming pregnant soon?*NoYes (please specify when)
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    • Are you breastfeeding?*NoYes
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