Adventure and Travel Medicine Center
33 West Rahn Rd. Suite 101 - Dayton, Ohio 45429
Phone: 937-438-7671 Fax: 937-438-7677
Pre-Travel Health Screening Form
Patient Name: Date:
Please, answer the questions on this sheet as best as you can. It will help us help you.
Purpose of Travel (Check one or more as applicable)
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Business |
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Vacation |
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Foreign Study |
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Missionary |
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Volunteer Agency: |
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Field Work |
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Teaching |
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Diving |
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Climbing |
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Other: |
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Type of Travel
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Guided Escorted Tour |
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Independent Travel: Fixed Itinerary |
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Independent Travel: Flexible Itinerary |
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Accommodations
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Camp |
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Hotel |
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Private Home |
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Rented Foreign Home |
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Resort |
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Safari |
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Youth Hostel |
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| Other: |
Total length of Trip: _______Days, ______Weeks, ______Months, ______Years.
Do you need a pre-travel exam & forms filled? Yes______. No_____.
Goal of your Travel Medicine Service visit ____________________________________________
Previous International Travel
Country:___________________ Year:_____ Country:__________________ Year:_____
Country:___________________ Year:_____ Country:__________________ Year:_____
Prior Immunizations (With dates)
| Flu Vaccine | Injectable Typhoid Vaccine (Typhim Vi) | ||
| Gamma Globulin | Oral Typhoid Vaccine | ||
| Hepatitis A Vaccine | BCG (TB) | ||
| Hepatitis B Vaccine | Rabies Vaccine | ||
| Japanese B Encephalitis Vaccine | TD (Tetanus, Diphtheria) | ||
| Lyme Disease Vaccine | Yellow Fever Vaccine | ||
| Meningococcal Vaccine | Other: | ||
| MMR (Measles, Mumps, Rubella) | Other: | ||
| Oral Polio (OPV) | Other: | ||
| Polio injection Vaccine (IPV) |
Did you have any adverse reaction to any of the above? Yes_____, No______. If yes, to which:______________________
If you were born after 1957, have you had measles? Yes____, No_____.
If not, have you been immunized against measles since 1980? Yes_____, No_____ .
Allergies: (Food, Drugs, Environmental factors)
| 1 | 3 | ||
| 2 | 4 |
Do you have a HISTORY of any of the following?
| Depression? | Yes____, No_____ | Hepatitis? | Yes____, No_____ |
| Other Psychiatric Problem? | Yes____, No_____ | Psoriasis? | Yes____, No_____ |
| Heart Rhythm Problem? | Yes____, No_____ | Seizure Disorder? | Yes____, No_____ |
Do you take any of the following medications?
| Quinidine | Yes____, No_____ | Beta Blocker | Yes____, No_____ |
| Quinine | Yes____, No_____ | Calcium channel blocker | Yes____, No_____ |
| Anti-seizure medication | Yes____, No_____ | Any other heart medication | Yes____, No_____ |
Please list your current medications/ hormones (Including over-the-counter and herbs)
| 1 | 4 | 7 | |||
| 2 | 5 | 8 | |||
| 3 | 6 | 9 |
Are you pregnant, or considering to become pregnant prior or during this stay abroad? Yes_____, No_____
Do you have any immune deficiency? Yes_____, No_____ .