* Required Information

Travel History Form

Travel Plans

(list additional information on back of form if needed)

Countries and Cities in order of visit Arrival Date Departure Date

Health History

Vaccination History

Have you received the following immunizations?


Prescription medications: List all current prescription medications and condition treated. (include birth control pills):

Prescription Medication Reason for Use/Medical Condition

Nonprescription products: List all over-the-counter, herbal, homeopathic products, vitamins, supplements etc.)

Nonprescription medications Reason for Use/Medical Condition

Women Only


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