Pre-Travel Form

Last, Middle, First
Today's Date
Date of Birth
Position Undergrad Graduate Law Staff/Faculty
Home Phone
Cell Phone
Email
None
Current Medical Problems
None
Past Medical Problems
None
Hospitalizations
None
Surgeries
Leukemia, lymphoma, cancer, or any other malignant diseases
Deficiency of the immune system
Anemia or any other blood disorder
Psoriasis
Chronic medical conditions involving the heart, liver, kidney, stomach, or colon
Depression, Anxiety, ADHD, eating disorder, sleep disturbance, or other Mental Health condition
Diabetes
Recent Chemo therapy, radiation, or steroid treatment
Hypertension / Heart Disease
Asthma, Emphysema, other Respiratory Disease
Seizure or other Nerologic disorders
Please Explain any checked boxes
Current Medications
None
Medications, Vaccinations, Foods, or Environment
Eggs
Mercury (thimerosal)
Bee Stings
Latex
Gelatin
Nuts
Other food allergies
Last Dental Exam
Last Physical Exam
Have you felt ill or had a fever in the past 48 hours? Yes No
If Yes please explain
Date of last menstrual period
Are you pregnant, suspect you may be pregnant, or trying to become pregnant? Yes No
Are you breastfeeding? Yes No
Date of Departure
Date of Return
Program sponsoring travel
Staff / Faculty contact
Purpose of travel
Do you have medical insurance? Yes No
If yes, does it include emergency medical evacuation? Yes No
Previous Interational Travel Yes No
Locations and dates
Country to be visited
Length of Stay
Country to be visited
Length of Stay
Country to be visited
Length of Stay
Country to be visited
Length of Stay
Major resort hotels
Cruise ships
Camping
Staying with a family
Small hotels
Safari
Scuba / Snorkel, Cave exploration, Biking, Wilderness, Hiking
Rented foreign home
Youth hostel
Rural travel at any time
Residence hall
High Altitudes (above 8000 ft)
Other
Are you traveling alone with a group both
Hepatitis A
Hep A vaccination date
Hepatitis B
Hep B vaccination date
Twinrix (combined hep A and B)
Twinrix vaccination date
Tetanus-diphtheria
Tetanus vaccination date
Tetanus-diphtheria-pertussis (Adacel)
Pertussis vaccination date
Varicella
Varicella vaccination date
Measles-mumps-rubella (MMR)
Measles vaccination date
Pnuemococcal
Pnuemococcal vaccination date
Typhoid (oral or injectable)
Typhoid vaccination date
Meningitis (menactra/menomune)
Meningitis vaccination date
Polio
Polio vaccination date
Yellow Fever
Yellow fever vaccination date
Japanese Encephalitis
Japanese encephalitis vaccination date
Rabies
Rabies vaccination date
Cholera (Not available in U.S.)
Cholera vaccination date
Previous Malaria Prevention
Malaria vaccination date
Mantoux (PPD/TB test)
Mantoux vaccination date
BCG vaccine
BCG vaccination date