Travel Medical History Form

CLIENT INFORMATION

First Name

Middle Name

Last Name

Sex

Male

Female

Date of Birth

Phone/Mobile

Residential Address

Address Line 1

Address Line 2

City

Province

Postal Code

Country

Emergency Contact Name

Relationship

Phone/Mobile

Primary Care Physician (if applicable):

Phone Number

MEDICAL HISTORY

Are you pregnant or are you trying to get pregnant?

Yes

Are/will you be breast feeding?

Yes

Have you ever had an abnormal Pap Test result?

Yes

Current Health Concerns:

Current medications (Include supplements and over-the-counter drugs):

Allergies:

No known allergies

Yes (Please specify):

List all known allergies:

Please specify your past medical conditions:

VACCINATION HISTORY

Have you received all your routine immunizations?

Yes

Not sure - I don't have a record

General Vaccination History

	Vaccinated 10+ yrs ago	Vaccinated within 10 yrs	Vaccinated Recently (this year)	Not Sure	Never Received
Tetanus
BCG
Diphtheria
Pertussis
Influenza
Pneumococcal
Meningococcal
Measles
Mumps
Rubella
Varicella (Chicken Pox)
HPV
Herpes Zoster (Shingles)
Rotavirus
Polio

Travel Vaccination History

	Vaccinated 10+ yrs ago	Vaccinated within 10 yrs	Vaccinated Recently (this year)	Not Sure	Never Received
ETEC/Cholera (Dukoral)
Hepatitis A
Hepatitis B
Japanese Encephalitis
Rabies
Typhoid
Yellow Fever
Chikungunya

Have you taken any medication for malaria prevention?

Yes

Which malaria medication have you taken?

Mefloquine

Malarone

Other/Cannot remember

Did you experience any side effects from the malaria medication?

Yes

TRAVEL ITINERARY

Date of departure

Returning

Please write your reason for the trip:

List the countries you plan to visit from first to last

Country	Length of stay (in days)	Accomodation	Area

What are your primary concerns regarding your health and safety during this trip?

AGREEMENT & CONSENT

I have read and agree to the Terms and Conditions, Privacy Policy and EHI Collection Policy.

I verify that the information entered in this form is true and correct to the best of my knowledge. By signing below, I confirm the accuracy of the provided information, consent to its use in my medical care, and acknowledge that I have read and agree to the Terms and Conditions and Privacy Policy.

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Travel Medical History Form

CLIENT INFORMATION

MEDICAL HISTORY

VACCINATION HISTORY

TRAVEL ITINERARY

AGREEMENT & CONSENT

COMPANY

UPDATES

SERVICES

LEGAL