INTERNATIONAL HEALTH MEDICAL QUESTIONAIRE
DATE: ______________
DATE OF BIRTH: __________________
AGE: ___________
NAME: _________________________________________________________________________
ADDRESS: ______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
PHONE: (H) _______________________
(C) ___________________________ EMAIL: __________________________________
How did you hear about us?
Primary Doctor ______
Family/Friend ______
Online Search ______ Our Website
______
CDC Directory ______
Reason for Travel:
Vacation ______
Business ______
Visiting Friends/Relatives _______
Volunteer Aide ______
Student _______
Medical Volunteer _______
Missionary _______
Adoptions _______
Travel Itinerary:
Country
Arrival
Departure
Duration
_________________
_________________
________________
_______________
_________________
_________________
________________
_______________
_________________
_________________
________________
_______________
Immunizations:
Please list the dates of any immunizations that you have received as an adult
Date(s) Received
Never had
Not Sure
Hepatitis A-2 doses
______________
________
_______
Hepatitis B-3 doses
______________
________
_______
Japanese Encephalitis-2 doses
______________
________
_______
Measles, Mumps, Rubella
______________
________
_______
Meningococcal
______________
________
_______
Pneumococcal
______________
________
_______
1
Name: _______________________________________
Immunizations:
Date of Birth: ____________________
Date: _______________
Please list the dates of any immunizations that you have received as an adult (cont.)
Date(s) Received
Never had
Not Sure
Polio
______________
________
_______
Rabies-3 doses
______________
________
_______
Tetanus, Diphtheria, Pertussis
______________
________
_______
Typhoid
______________
________
_______
Varicella (Chicken Pox)- 2 doses
______________
________
_______
Yellow Fever
______________
________
_______
Zoster (Shingles)
______________
________
_______
Medical History:
YES
NO
Psychiatric problems
_______
_______
Irregular heart beat
_______
_______
Psoriasis
_______
_______
Seizures
_______
_______
Immune suppressive medications
_______
_______
Heart disease
_______
_______
Immunity problems
_______
_______
Please explain any of “Yes” answers:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Allergies:
Medication
YES
_______
NO
_______
Name
____________________
Vaccine
_______
_______
____________________
Bee Stings
_______
_______
____________________
Food
_______
_______
____________________
2
Name: _______________________________________
Date of Birth: ____________________
Date: _______________
Please list all current medications:
Name of Medication
Condition or Reason for use
1.
________________________________
____________________________________
2.
________________________________
____________________________________
3.
________________________________
____________________________________
4.
________________________________
____________________________________
5.
________________________________
____________________________________
6.
________________________________
____________________________________
Please answer the following questions:
• Have you ever fainted from having you blood drawn or from an injection?
• Have you ever had any bad reaction or side effects from any vaccination?
• Do you live (or work closely) with anyone who has AIDS, an AIDS condition,
any other immune disorder, or who is on chemotherapy for cancer?
• Do you have medical condition that warrants maintenance medications or physician follow up?
Condition: _______________________________________________________
• Are you pregnant or might you become pregnant on this trip?
(MMR, or components, Oral Typhoid, Varicella, Yellow Fever, most other immunizations if in first
trimester, Doxycycline and other antibiotics)
• Do you have AIDS, any AIDS-like condition, any other immune disorder, Leukemia or Cancer?
(MMR or components, Oral Typhoid, Rabies, Yellow Fever)
• Do you have severe Thrombocytopenia (low platelet count) or a coagulation disorder?
(Any intramuscular injection)
• Have ever had a convulsion, seizure or epilepsy? (Mefloquine, Pertussis)
• Do you have a history of depression or any psychiatric problems? (Mefloquine)
• Do you have a problem with nightmares? (Mefloquine)
• Do you have psoriasis? (Choloroquine)
YES
NO
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
In the past 3 months, have you taken:
• Cortisone
•Prednisone
•Steroids
•Cancer medications
•Had Radiation treatments
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
3
Name: _______________________________________
Date of Birth: ____________________
Date: _______________
Are you taking or will you be taking:
YES
NO
• Medication for a cardiac condition? (Mefloquine)
• Steroid, Prednisone or Cortisone? (MMR or components, Oral Typhoid, Rabies, Varicella or
Yellow Fever)
• Antibiotics (Oral Typhoid)
_____
_____
_____
_____
_____
_____
• Oral Contraceptives (Doxycycline, Tetracycline)
• Medications for emotional problems or seizure disorder? (Mefloquine)
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
_____
Are you Allergic to:
• Penicillin or sulfa (Diamox, Penicillin or Sulfa)
• Mercury or Thimersal (DTP, DtaP, DT, Td, Hib, Japanese encephalitis, Fluvirin,
Hepatitis B, IG, Influenza, Meningococcal, Pneumococcal, Rabies
• Neomycin (Influenza-Fluvirin, IPV, MMR or components, Rabies or Varicella)
• Polymyzin (Influenza-Fluvirin, IPV)
• Streptomycin (Influenza-Fluvirin, IPV)
• Aluminum or aluminum hydroxide (Hepatitis A, Ck other pkg, inserts)
• Bee Stings or have a history of hives or Urticaria (Japanese encephalitis)
• Yeast (Hepatitis B)
• Eggs (Influenza, MMR or components or Yellow Fever)
The above information is complete and accurate to the best of my knowledge. I hereby consent to consultation, treatment and
administration of vaccines by the provider. I understand that payment in full by cash or credit card is due at the time of the visit.
The provider does not bill insurance or any third party payor. A portion of the charges may be reimbursable by insurance.
Traveler / Parent Signature: ______________________________________________ Date: _________________
Physician Signature: ____________________________________________________ Date: _________________
Nurse/ Medical Assistant: _______________________________________________ Date: _________________
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