Travel Health Form

Please fill out, print, and bring this form to your Travel Consultation Appointment.  This information will be used to assess your health needs prior to your travel. Also bring your immunization card.    


Name:

Phone Number:

Student ID#: Date of Birth:   
Address: Sex:MaleFemale
City:

Purpose of Trip: School Related Pleasure Other
Length of Stay:

Type of Accommodations:

Are you enrolled in a health insurance plan that covers you while overseas? Yes No

Does your program require the completion of a medical form? Yes No

Have you traveled outside the United States before? Yes No

If yes give the names/dates of travel immunizations received.

Immunizations                                         Date received Immunizations Date received
      
      
      
Countries to be visited in order of visits Arrival Date Departure Date Urban or Rural

MEDICAL HISTORY

Drug Allergies:, ,

Medical Problems:,,

Current Prescription Medication Reason for use
1.
2.
3.
4.
5.

 

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