Travel Questionnaire
North Shore Travel Medicine, LLC.
Date: _________
Name (last, first) ______________________________Date of Birth _____________ Age _______
________________________________________________________________________________
Street Address
_________________________________________________________________________________
City, State, Zip
Phone Number: ______________________________________ Gender: ␣ M ␣ F
Departure Date: _____________ Return Date: _____________ Length of stay (Days): _________
Country (s) in order of travel:
________________________________________________________________________________________________________
____________________________________________________________
Please indicate what your travel plans include by answering all of the following questions
(check all that apply)
Is your journey related to:
␣ Business ␣ Tourism ␣ Study␣ Visiting Homeland
Travel Accommodations:
␣ Resort ␣ Hostel ␣ Private Home ␣ Camping ␣ Economy
Will your visit be:
␣ Urban ␣ Rural␣ Combined
Anticipated travel activities:
␣ Biking ␣ High altitude visit ␣ Scuba diving ␣ Sight seeing
␣ High altitude climb␣ Medical work ␣ Hiking/trekking
________________________________________________________________________
MEDICAL HISTORY
Are your aware of any allergies: ␣Yes ␣No
Specific Antibiotics or Medications: ___________________________________________________
Bee Stings (experience hives?) Yeast or Eggs: ___________________________________________
Other allergies ____________________________________________________________________
Medications: Please list ALL medications that you take (name of medication only)
________________________________________________________________________________________________________
________________________________________________________________________________________________________
______________________________________
Please answer Yes or No to ALL questions:
Questions
Have you had a recent tetanus shot? Year?
Have you received the Hepatitis B vaccine?
Are you pregnant?
Might you become pregnant traveling?
Do you take steroids such as prednisone?
Do you have AIDS, Leukemia, or Cancer?
Do you have a family history of immunodeficiency?
Do you work or live with anyone that has AIDS,
Leukemia, or Cancer?
Are you allergic to eggs?
Have you had a fever in the past 48 hours?
Have you had a prior fever reaction to vaccines?
Are you allergic to sulfites?
Are you allergic to neomycin, polymysin, or
streptomycin?
Are you allergic to yeast?
Do you have heart, kidney, or liver disease?
Are you experiencing an active illness now?
Yes
No
Concerns
Most vaccines except Td
Most immunizations
MMR, OPV, Rabies, Oral
Typhoid, and Yellow Fever
MMR, OPV, Rabies, Oral
Typhoid, Yellow Fever,
and Japanese Encephalitis
OPV
OPV
Influenza, MMR, Yellow
Fever
Td, Tdap, Influenza,
Pneumococcal, and Oral
Typhoid
Tdap, Td, and Typhoid
injection
Influenza
MMR, IPV, OPV
Hepatitis B
Japanese Encephalitis
Do you have any eye conditions?
Do you have any skin problems?
Do you have any stomach conditions?
Have you ever had Hepatitis or Yellow Fever?
Do you have insomnia?
Do you have any major medical conditions?
Do you have a history of fainting with shots?
Have you ever reacted positive to a TB test?
Medications
Do you have any medication allergies?
Have you ever had a seizure?
Are you on any heart medications?
Will you be taking Chloroquine or Mefloquine ?
Are you taking any antibiotics?
Oral Typhoid, OPV
Mefloquine, Pertussis
Mefloquine
Rabies, Oral Typhoid
Oral Typhoid
The above information is accurate to the best of my knowledge. I understand that insurance may not cover travel related
immunization services and that I am responsible for all fees due at time of service. I understand that I will be given an
immunization record listing all vaccines received and that I am responsible for keeping this safe and up-to-date. Inactive records
are kept on file for 3years and are confidential.
Traveler/patient signature: ______________________________________ Date: ____________
Physician: ____________________________________________________ Date: ____________
Please print form then and return it to the Travel Clinic prior to your appointment.
Fax: to secure fax number: 440-471-7113
Mail to: North Shore Travel Medicine, LLC. 25757 Lorain Road North Olmsted, OH 44070