Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Travel Health History Form
Your information
Full Name *
Travel Destination(s)
Travel Dates
____ / ____ / ________
Type of Travel
Activities & Exposure Risks
Travel Vaccinations Received
Malaria Prophylaxis Regimen
Additional details
Existing Medical Conditions
Current Medications
| Medication | Dose | How often |
|---|---|---|
Post-Travel Symptom Screen
Symptom Onset Date
____ / ____ / ________
Fever Pattern Description
Prior Travel History
Patient Signature
Date
Travel Health History Form template from formisoft.com. formisoft.com/intake-templates/travel-health-history