Eastern Michigan University
University Health Services
Travel Health Clinic
TRAVEL INFORMATION FORM
*This form must be filled out and turned in to UHS one week prior to travel health clinic visit*
Name:
ID#:
Date:
E-mail:
Phone:_______________________________________
Date of Birth:
Country of Birth:_____________________________
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_
Local Address:
Perm. Address: :
TRAVEL INFORMATION
Departure Date:
Return Date:
Please indicate all the countries to which you will be traveling in the order in which you will visit them and
indicate the length of time you will stay in each country. Add additional pages if necessary.
Destination
Where will you stay?
Length of stay
Rural/Urban
Please check all that apply to your travel plans
Major resort hotels
Staying with a family
Rented foreign home
High altitudes >12000ft
Cruise Ship
Small hotels
Youth Hostels
Camping/Tenting
Safari
Rural travel
Outdoor activities
Contact with animals
What is the purpose of your travel? Please check all that apply
Business
Teaching
Study
Volunteer Agency
Vacation
Field Work
Missionary
Climbing
Other:
Significant insect exposure
Working in Medical/Dental field
Exposure to poor sanitation
Other
HEALTH HISTORY
Do you see a medical specialist? (Y/N) Reason:
Medical Diagnoses (if any)
______________________________________________
_____________________________________________
_______________________________________________
Over the Counter Medications (if any)
______________________________________________
_____________________________________________
_______________________________________________
Medications/Vaccine Allergies (if any)
______________________________________________
_____________________________________________
_______________________________________________
Food Allergies/Intolerances (if any)
______________________________________________
_____________________________________________
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Medication and Dose
______________________________________________ ______
_____________________________________________ _______
_______________________________________________ _____
Reason for taking
______________________________________________ ______
_____________________________________________ _______
_______________________________________________ _____
Specific Reaction
______________________________________________ ______
_____________________________________________ _______
_______________________________________________ _____
Specific Reaction
______________________________________________ ______
_____________________________________________ _______
_______________________________________________ _____
Diet: Regular Vegetarian Other (describe):
Are you allergic to eggs? Yes No
Bee Stings? Yes
No
Do you carry an EpiPen? Yes
No
PLEASE INDICATE IF ANT OF THE FOLLOWING AFFECTS YOU:
Problem
Yes
No
Medications or Remedy
Motion Sickness
Fear of Flying
Urinary Tract Infections
Severe Headaches
Asthma
Seizures
Blood Clots
MENTAL HEALTH
Ever been hospitalized for a mood or psychiatric reason? (Y/N) If yes, when?
Ever been treated for a psychiatric problem or eating disorder? (Y/N) What diagnosis?
Have you ever been counseled or medically treated for depression or anxiety? (Y/N)
Explain:
Do you currently take medications for depression or anxiety? (Y/N) Please list:
Are you currently undergoing counseling for any reason? (Y/N) Explain:
Ever have significant difficultly with the stress of traveling? (Y/N) Explain:
Do you have any additional health conditions other than those previously listed that may need special
consideration before or during your study abroad experience or may affect your ability to participate in this
program? (Y/N) Explain:
VACCINATION INFORMATION
The following vaccination information can be obtained from your immunization record, your local health
department, or from your physician’s office where you received your immunizations.
I am up to date on all childhood immunizations. (Y/N)
Date of last tetanus booster:
Did you receive the Hepatitis B vaccine series? (Y/N) If yes, please list dates
Dates of Hepatitis B series: 1)
2)
3)
Have you received an influenza vaccination this year? (Y/N)
HAVE YOU RECEIVED THE FOLLOWING SPECIAL OR TRAVEL RELATED VACCINE?
Vaccine
No
Yes
If yes, give date(s)
Hepatitis A
Yellow Fever
Injected Typhoid
Oral Typhoid
Adult Polio Booster
Meningitis
Rabies
Encephalitis (Japanese)
Have you had a tuberculin skin test (PPD) in the past? (Y/N) Was there a reaction?
Do you know of any specific vaccinations or medications required for your trip? (Y/N) Please list
Have you ever taken medication to prevent malaria? (Y/N) Any side effects?
If known, which medication did you take?
WOMEN ONLY
Are you currently pregnant or breast feeding? (Y/N)
I certify that the responses on this form are complete, accurate, and true. I understand that it is my
responsibility to inform UHS if there are any changes in my health information.
Patient Signature:
Date:
UHS Staff Signature:
Date: