UNIVERSITY HEALTH SERVICES (UHS)
International Travel Medical Questionnaire
Date
Print Name (Last, First)
Penn State Student ID Number
____________
DOB
__________________________________________________________________________ ________________________________
Address
Contact Phone #
ITINERARY
Date of Departure:
Return Date:
Please indicate, in the order you will visit them, the countries you are traveling to. Also indicate length of stay in each country.
Destination (City, Country)
Where will you stay?
Length of stay
Please circle all that apply to your travel plans:
Major Resort Hotels
Cruise Ships
Camping
Safari
Outdoor Activities
Rented Foreign Home
What is the purpose of travel? (Please Circle)
Business
Student
Vacation
Field Work
Climbing
Diving
Please circle all the vaccines you have had:
Cholera
Immune Globulin
Diphtheria
Japanese Encephalitis
Flu Vaccine
Malaria Drugs
Hepatitis A
Measles
Hepatitis B
Meningococcal
Rural Travel
Youth Hostel
Missionary
OTHER:
Teacher
Mumps
Pertussis
Plague
Pneumococcal
Polio (Oral or Injectable)
Do you have a current Travel Immunization Record?
 Yes
Staying With a Family
OTHER:
Rabies
Rubella
Smallpox
Tetanus
Tuberculin Test
Small Hotels
Volunteer Agency
Typhoid (Oral or injectable)
Varicella
Yellow Fever
 No
IMMUNIZATIONS
Have you ever fainted from having your blood drawn or from an
injection?
Have you had a fever reaction to a vaccination?
YES

NO

PROBLEM*


Any vaccine, especially those containing
tetanus-diphtheria
Have you ever had any bad reaction or side effect from any
vaccination?
Have you ever had Hepatitis A or B vaccine?
Do you live (or work closely) with anyone who has AIDS, an
AIDS-like condition, any other immune disorder, or who is on
chemotherapy for cancer?
Do you have a family history of immunodeficiency?
Have you received any injection of immune globulin or any blood
product during the past 12 months?










132(b) 4-CS 03/13
Varicella, Smallpox, FluMist, MMRV,
Zostavax
Varicella, Smallpox, MMRV, Zostavax
Varicella, Measles-containing vaccine,
Smallpox, MMRV, Zostavax
PATIENT REGISTRATION FOR TRAVEL
Page 1 of 4
UNIVERSITY HEALTH SERVICES (UHS)
International Travel Medical Questionnaire
Date
Print Name (Last, First)
GENERAL MEDICAL
Penn State Student ID Number
____________
DOB
YES
NO










Are you breastfeeding?
Do you have HIV, AIDS, an AIDS-like condition, immune deficiency or
other immune disorder, leukemia, or cancer, or are you taking
immunomodulatory drugs or are you post-transplant?
Do you have severe combined immunodeficiency disease?
Do you have a history of problems with your thymus, such as myasthenia
gravis, DiGeorge syndrome, or thymoma?
Do you have severe thrombocytopenia (low platelet count) or a
coagulation disorder?
Have you ever had a convulsion, seizure, epilepsy, neurologic condition,
or brain infection?
Do you have any stomach conditions?








MMR, Oral typhoid, Smallpox, Varicella,
Yellow fever, MMRV, Influenza (FluMist),
Influenza H1N1 (intranasal Zostavax),
Japanese encephalitis, HPV (Gardasil),
Doxycycline and other antibiotics. For other
immunizations weigh the theoretical risk of
vaccination against the risk of disease.
Smallpox, yellow fever, adenovirus
MMR, Oral typhoid, Smallpox, Rabies,
Varicella, Yellow fever, FluMist, MMRV,
Zostavax, Rotavirus, adenovirus
Rotavirus
Yellow fever


Any intramuscular injection


Mefloquine, DTaP, Tdap, MMRV


Do you have a G6PD deficiency?
Do you have severe renal impairment?
Do you have bowel conditions such as diarrhea or constipation?
Do you have congenital malformation of the GI tract or chronic GI
disorder?
Have you ever had hepatitis or yellow jaundice?
Do you have a history of psychiatric problems?
Do you have a problem with strange dreams and/or nightmares?
Do you have insomnia?
Do you have problems with vaginitis?
Do you have psoriasis?
Have you or a member of your household ever been diagnosed with
eczema or atopic dermatitis?
Cardiac disease, with or without symptoms?
Do you have any eye conditions?
Are you prone to motion sickness?
Do you have asthma or wheezing?
Do you have multiple sclerosis?








Oral typhoid, Mefloquine, Doxycycline,
Malarone, Chloroquine, Rotavirus
Chloroquine, Primaquine
Malarone
Rotavirus
Rotavirus














Mefloquine
Mefloquine
Mefloquine
Any antibiotic
Chloroquine or related compounds
Smallpox










Do you have a medical condition that warrants maintenance
medications or physician follow-up?
Do you have a medical condition that is stable now, but that may
recur while traveling?
Have you had an acute illness or a fever in the past 48 hours?
Do you have asplenia?
Are you pregnant* or might you become pregnant on this trip?
First day of your LMP? ___________________
132(b) 4-CS 03/13
PATIENT REGISTRATION FOR TRAVEL
PROBLEM*
Smallpox, FluMist
FluMist
Yellow Fever
Page 2 of 4
UNIVERSITY HEALTH SERVICES (UHS)
International Travel Medical Questionnaire
Date
Print Name (Last, First)
MEDICATIONS
ARE YOU TAKING OR WILL YOU BE TAKING:
Quinine, quinidine or medications for a cardiac conduction defect?
Chloroquine, mefloquine, or proguanil to prevent malaria?
Proguanil to prevent malaria?
Steroids, prednisone, cortisone or anti-cancer drugs?
Penn State Student ID Number
YES
NO






















YES
NO








Streptomycin?
Gentamicin?
Neomycin?






Polymyxin?


Kanamycin?
Sulfites?
Sodium metabisulfite?
Protamine sulfate?
Aluminum or aluminum hydroxide?










Benzethonium chloride?
2-phenoxyethanol?




Yeast?


Eggs, egg protein, ovalbumin, or chicken protein?


Chlortetracycline?
Latex?
Gelatin?






Antibiotics or sulfonamides?
Ketoconazole?
Pepto-Bismol to prevent travelers' diarrhea?
Antacids?
Aspirin therapy (children and adolescents)?
Medications for emotional problems?
Medications for convulsions?
ALLERGIES
ARE YOU ALLERGIC OR HYPERSENSITIVE TO:
Any medications?
Amphotericin B?
Penicillin or sulfa?
Mercury or thimerosal?
132(b) 4-CS 03/13
PATIENT REGISTRATION FOR TRAVEL
____________
DOB
PROBLEM*
Mefloquine
Oral typhoid
MMR or components, Oral typhoid,
Varicella, Yellow fever, FluMist, MMRV,
Zostavax
Oral typhoid
Mefloquine
Doxycycline, tetracycline
Doxycycline, tetracycline
Varicella, FluMist
Mefloquine
Mefloquine
PROBLEM*
RabAvert
Diamox®, Fansidar®, Penicillin, Sulfa
See Table THIM-1 (U.S.) or Table THIM-2
(Canada)
IPV
FluMist, Fluarix
Havrix, Hep A/B, Influenza (Afluria,
Fluviron, Agriflu), IPV, MMR, Rabies,
Varicella, Zostravax, MMRV, Pediarix,
Smallpox (ACAM2000), Kinrix, Pentacel
Influenza (Fluvirin, Afluria), IPV, Pediarix,
smallpox (ACAM2000), Kinrix, Pentacel
Agriflu
Doxycycline
IXIARO
IXIARO
Anthrax, Hep. A, Hep. B, Hep A/B,
COMVAX, DTaP, Td, Rabies (RVA),
PCV, Tdap, TBE, HPV, Kinrix, Pentacel,
IXIARO, Pediarix, HPV, DT, PedvaxHib
Anthrax
Hep. A (Havrix), Hep. A/B (Twinrix),
IPV, DTaP, (Infanrix, PEDIARIX), Tdap
(ADACEL), Pentacel
Hepatitis B, Hepatitis A/B (Twinrix),
PEDIARIX , Comvax, PCV, oral typhoid,
Gardasil
Influenza (seasonal), Rabies (PCEC), Yellow
fever, MMR, MMRV, TBE
Rabies (PCEC)
Consult package insert
Varicella, MMR, Yellow Fever, Rabies,
Page 3 of 4
UNIVERSITY HEALTH SERVICES (UHS)
International Travel Medical Questionnaire
Date
Print Name (Last, First)
Penn State Student ID Number
Soy?
Lactose?
Bovine/calf/fetal serum albumin, protein, or extract?






Formaldehyde or formalin?


____________
DOB
Fluzone, oral typhoid, MMRV, Zostavax
PCV, Comvax, Recombivax
Menomune, oral typhoid, HIBERIX, BCG
Ixiaro, Infanrix, Kinrix, Pediarix, Pentacel,
DT (sanofi), Vaqta, IPV, MMR, MMRV,
PPSV, RabAvert, RotaTeq, Td (Decavac),
Boostrix, oral typhoid, varicella, Zostavax
Ixiaro, BioThrax, DTaP, Hiberix, ACTHib,
Comvax, DT, Pentacel, Pediarix, Kinrix,
HepA, Recombivax, HepA/B, influenza
(Agriflu, Fluarix, Flulaval, Fluzone), IPV,
MCV4, Td, Tdap, MenHibrix
*Note: A “problem” listed above may be a contraindication or merely a precaution or merely an issue that warrants further discussion between the health
care provider and patient to discuss risks/benefits of vaccination with that particular vaccine. The above “problem” list presents some common issues
that arise in a pre-travel consultation but is not all-inclusive. Likewise, the list of allergies, hypersensitivities, and vaccine excipients is not
comprehensive: providers should always check package inserts carefully. See CDC’s Epidemiology and Prevention of Vaccine – Preventable Diseases
(the “Pink Book”) and Appendix B for a complete list of vaccine excipients.
COMMENTS:
SIGNATURE OF TRAVELER:
DATE:
SIGNATURE OF UHS HEALTH CARE PROVIDER:
DATE:
The information in this questionnaire is not a substitute for medical advice from a health care provider on an individual basis.
132(b) 4-CS 03/13
PATIENT REGISTRATION FOR TRAVEL
Page 4 of 4
UNIVERSITY HEALTH SERVICES FINANCIAL INFORMATION FORM Typically there are charges for your travel service visit and for any immunizations. 1. Is a Penn State college/department responsible for paying the charges? _ ____ Yes _ ____No If yes, complete the following: Name of Departmental Contact Person: ____________________________ College/Department: ___________________________________________ Building Address for Contact Person:_______________________________ Phone Number for Contact Person: ________________________________ 2. If the answer to Question 1 is No, the charges can be paid at the front desk at the day of your visit, or will be posted to your student/nonstudent account at the Bursar’s Office. _________________________________________ PRINT NAME PATIENT NAME _________________________________________ ______________ Patient’s Signature Date ___________________ PSU ID # Distribution: Financial Services 308 Student Health Center 06/01/2010 Page 1 of 1