International Travel Questionnaire
The answers you supply in this questionnaire will enable us to give the most accurate medical information and advice for your
specific travel plans. Please fill this out completely prior to your travel appointment. The more details you can provide
regarding your itinerary, the better we can prepare you for a safe and healthy travel experience. Please bring with you, or verify,
that we have a copy of your immunization records.
Name: ____________________________________ DOB: ___________________ Student ID#:___________________________
Phone #:_________________ Country of Birth: __________________________ Email Address: ________________________
Main Country of Stay: ______________________ Departure Date: ________________ Return Date: ___________________
1. What is the purpose of your travel? (Study abroad, vacation, volunteer, medical mission, etc.)_____________________________
2. Please list all the countries, in order of travel, that you will be visiting, or consider visiting:
1. Country____________________ Region/Cities_______________________ Travel Date/Duration__________________
2. Country____________________ Region/Cities_______________________ Travel Date/Duration__________________
3. Country____________________ Region/Cities_______________________ Travel Date/Duration__________________
4. Country____________________ Region/Cities_______________________ Travel Date/Duration__________________
5. Country____________________ Region/Cities_______________________ Travel Date/Duration__________________
*For travels to multiple destinations, attach a separate sheet of paper. If you have a specific itinerary with travel dates, please
bring it to your appointment.*
3. What is your living situation going to be? (Home stay, dorm, hostel/hotel, camping, etc…)_______________________________
4. Please list all planned and possible activities (backpacking, hiking, high altitudes, scuba diving, etc…) _____________________
________________________________________________________________________________________________________
5. Travel Style: Independent Package Tour Adventure trip
6. Are you visiting friends and relatives? No Yes
7. Do you have any health concerns regarding your travel? ___________________________________________________________
8. Have you have any medical or psychiatric problems? No Yes, please explain: __________________________
________________________________________________________________________________________________________
9. Is there any chance you could be pregnant? No Yes N/A
10. Do you smoke? No Yes
11. Do you have any allergies to medications, food, etc.? No Yes, please list: __________________________________
12. What regular medications are you taking? ______________________________________________________________________
13. List any previous travel experience you have outside of the United States: ____________________________________________
14. Have you taken Malaria medication before? No Yes
15. Have you taken Travelers Diarrhea medications before? No Yes
16. Do you have problems with high altitudes? No Yes
17. Have you had any other illness related to prior travel? No Yes, please explain: ____________________________
18. Do you have a form that requires a physician’s signature? No Yes N/A
19. Are you currently enrolled in a health insurance plan that covers you while overseas? No Yes
20. Do you have a current passport or visa? No Yes
Appointment Date: ________________________ Time: _______________________
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For Health Center Staff Only
Immunization History
Please attach a copy of immunization record
Hepatitis A #1_______________ #2__________________
Hepatitis B #1_______________ #2__________________ #3__________________ #4_______________
Twinrix #1_______________ #2__________________ #3__________________ #4_______________
HPV #1_______________ #2__________________ #3__________________
Influenza _______________
Japanese Encephalitis #1______________ #2_______________
MMR #1______________ #2_______________
Meningococcal _______________
Polio _______________
PPD (placed) _______________ (Read) _______________
Rabies #1_______________ #2__________________ #3__________________
Tdap/Td _______________
Typhoid (oral) _______________ Injectable: _____________
Varicella #1_______________ #2__________________
Yellow Fever ________________ Other_________________
Nursing Notes
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