Travel Health History Form
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Travel Health History Form
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The Travel Health History Form is designed for travel medicine clinics and infectious disease practices that evaluate patients before and after international travel. It captures a detailed travel itinerary including countries and regions visited, duration of stay, type of travel (urban, rural, adventure, medical tourism), accommodation types, and activities with potential exposure risk such as freshwater swimming, cave exploration, animal contact, or healthcare facility visits.
Pre-travel documentation includes required and recommended vaccinations for destination countries (yellow fever, typhoid, Japanese encephalitis, meningococcal, rabies pre-exposure), malaria prophylaxis regimen (atovaquone-proguanil, doxycycline, mefloquine), altitude sickness prevention, travelers' diarrhea self-treatment kits, and any destination-specific health advisories. The form cross-references the patient's existing immunization record and medical history to identify contraindications or special considerations for recommended prophylaxis.
Post-travel assessment sections screen for fever, gastrointestinal symptoms, respiratory illness, skin lesions, and neurological symptoms that may indicate travel-acquired infections such as malaria, dengue, Zika, chikungunya, typhoid, schistosomiasis, or tuberculosis. Incubation period timelines help providers correlate symptom onset with specific exposures. This form is used by travel medicine clinics, infectious disease practices, occupational health departments managing international assignees, and military medicine programs.
What's included
- Detailed travel itinerary and exposure risk documentation
- Destination-specific vaccination requirement tracking
- Malaria prophylaxis and chemoprevention recording
- Post-travel symptom screening and incubation timeline
- Cross-reference with existing medical and immunization history
- Travel-acquired infection differential documentation
- Medical conditions checklist
- E-signature capture
- Structured medication list with dosage and frequency tracking
Who uses this template
- Pre-travel consultation and prophylaxis planning
- Post-travel fever and illness evaluation
- Occupational health international assignee clearance
- Infectious disease endemic exposure assessment
All form fields
14 fields across 2 pages. Customize any field after signing up.
How to use the Travel Health History Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Travel Health History Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Travel Health History Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 14 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Travel Health History Form HIPAA compliant?
Yes. All Formisoft templates, including the Travel Health History Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 14 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Travel Health History Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Travel Health History Form for your practice. Set up in minutes.
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