| Last, Middle, First |
|
| Today's Date |
|
| Date of Birth |
|
| Position |
Undergrad
Graduate
Law
Staff/Faculty
|
| Home Phone |
|
| Cell Phone |
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| Email |
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| None |
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| Current Medical Problems |
|
| None |
|
| Past Medical Problems |
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| None |
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| Hospitalizations |
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| None |
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| Surgeries |
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| Leukemia, lymphoma, cancer, or any other malignant diseases |
|
| Deficiency of the immune system |
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| Anemia or any other blood disorder |
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| Psoriasis |
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| Chronic medical conditions involving the heart, liver, kidney, stomach, or colon |
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| Depression, Anxiety, ADHD, eating disorder, sleep disturbance, or other Mental Health condition |
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| Diabetes |
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| Recent Chemo therapy, radiation, or steroid treatment |
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| Hypertension / Heart Disease |
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| Asthma, Emphysema, other Respiratory Disease |
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| Seizure or other Nerologic disorders |
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| Please Explain any checked boxes |
|
| Current Medications |
|
| None |
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| Medications, Vaccinations, Foods, or Environment |
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| Eggs |
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| Mercury (thimerosal) |
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| Bee Stings |
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| Latex |
|
| Gelatin |
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| Nuts |
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| Other food allergies |
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| 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 |
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| 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 |
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| 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 |
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| Major resort hotels |
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| Cruise ships |
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| Camping |
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| Staying with a family |
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| Small hotels |
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| Safari |
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| Scuba / Snorkel, Cave exploration, Biking, Wilderness, Hiking |
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| Rented foreign home |
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| Youth hostel |
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| Rural travel at any time |
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| Residence hall |
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| High Altitudes (above 8000 ft) |
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| Other |
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| 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 |
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| Tetanus-diphtheria-pertussis (Adacel) |
|
| Pertussis vaccination date |
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| 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 |
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| Polio |
|
| Polio vaccination date |
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| Yellow Fever |
|
| Yellow fever vaccination date |
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| Japanese Encephalitis |
|
| Japanese encephalitis vaccination date |
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| Rabies |
|
| Rabies vaccination date |
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| Cholera (Not available in U.S.) |
|
| Cholera vaccination date |
|
| Previous Malaria Prevention |
|
| Malaria vaccination date |
|
| Mantoux (PPD/TB test) |
|
| Mantoux vaccination date |
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| BCG vaccine |
|
| BCG vaccination date |
|