Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Travel Medicine Intake Form
Your information
Full Name *
Date of Birth
____ / ____ / ________
Phone Number
Email Address
Travel Destinations
Travel Dates & Duration
Purpose of Travel
Planned Activities & Exposures
Accommodation Type
Additional details
Immunization History
Current Medications
| Medication | Dose | How often |
|---|---|---|
Chronic Medical Conditions
Allergy History
| Allergy | Reaction |
|---|---|
Pregnancy Status
- Pregnant
- Not pregnant
- Not sure
- Prefer not to answer
Prior Travel-Related Illness
Previous Travel Experience
Insurance & Evacuation Coverage
Consent & Signature
Date
Travel Medicine Intake Form template from formisoft.com. formisoft.com/intake-templates/travel-medicine-intake