Pre-Travel Health Assessment Form Step 1 of 9 11% Personal DetailName* First Last Address* (street, city, postal code) Weight*(in pounds)Provincial health care number*Date of Birth* (dd/mm/yyyy)Gender*MaleFemaleTelephone numberCell*Email* Family Doctor*Doctor phone number* Insurance InformationGroup planCertificate numberGroup numberCarrier Personal Medical HistoryWomen: Are you pregnant or breastfeeding?*YesNoAre you travelling with young children?*YesNoHave you been told you have a weakened immune system?*YesNoAre you doing charity work overseas? (refugee camps, missionary work)*YesNoAre you feeling well today?*YesNoDo you or a family member have epilepsy?*YesNoIs your health generally good?*YesNoDoes anyone in your household have a lowered immunity?*YesNoHave you ever fainted or felt unwell after an injection?*YesNoDo you have a history of mental illness such as depression or anxiety?*YesNoAny serious reaction to a vaccine?*YesNoAny vaccines in the last month?*YesNoAre you currently taking any steroid medications?*YesNoAre you allergic to eggs, any antibiotics, or latex?*YesNoHave you suffered from:Jaundice/hepatitis*YesNoBlood clots*YesNoEar/hearing problems*YesNoCancer/chemotherapy*YesNoHIV/AIDS*YesNoDiabetes*YesNoHeart disease*YesNo Current Medications & AllergiesPlease List all Current Medications (prescription or over-the counter):1.2.3.4. Please List all Current Medications (prescription or over-the counter): None Please List any Allergies: (food or medications)1.2.3. Please List any Allergies: (food or medications) None Please list any other medical conditions:1.2.3. Please list any other medical conditions: None Immunization HistoryAre your regular immunizations up-to-date?*YesNoNot sureWhen was the date of your last tetanus shot? (dd/mm/yyyy)When was the date of your last tetanus shot? Not sure Have you had the: Annual flu vaccine*YesNoNot surePneumonia vaccine*YesNoNot sureChicken pox vaccine*YesNoNot sureMMR vaccine*YesNoNot sure Travel vaccine HistoryHave you ever received the following immunizations?Hepatitis A*YesNoNot sureHepatitis B*YesNoNot sureRabies*YesNoNot sureYellow Fever*YesNoNot sureJapanese encephalitis*YesNoNot sureTick borne encephalitis*YesNoNot sureTyphoid*YesNoNot sureDukoral*YesNoNot sureMeningitis*YesNoNot sure Trip DetailsDate of departure from Canada:* (dd/mm/yyyy)Date of return to Canada:* (dd/mm/yyyy)Travel DetailsCountry | Town/City | Urban/Rural | Accommodations | Time spent in this country*Country | Town/City | Urban/Rural | Accommodations | Time spent in this countryCountry | Town/City | Urban/Rural | Accommodations | Time spent in this countryCountry | Town/City | Urban/Rural | Accommodations | Time spent in this countryCountry | Town/City | Urban/Rural | Accommodations | Time spent in this countryCountry | Town/City | Urban/Rural | Accommodations | Time spent in this countryCountry | Town/City | Urban/Rural | Accommodations | Time spent in this countryRate your Travel ExperienceTravel Experience:*New travellerLocal trips never overseasTravelled overseasExperienced traveller Please provide additional information about your tripReason for Travel*BusinessPleasureHoliday Type*PackageCampingSelf-organizedCruise shipBackpackingTrekkingMost common type of accommodation*Premium hotelBudget hotelHostelsFriends/family homeCampingWho is travelling with you?*SoloWith family/friendGroupAre any of the following activities be included in your trip plans? (please check all that apply)* Scuba diving Adventure travel Going to a high altitude Exposure to extreme heat or cold Safari Jungle Spending time in rural communities Other: Primary concerns & any other concerns not discussed on formPlease let us know your primary concerns with your trip or this travel health assessment (check all that apply)* Getting sick while away Who to contact if emergency occurs overseas Travellers’ diarrhea Travel insurance Safety and efficacy of vaccines Personal safety overseas Antimalarial medications Tips to lower your risk of getting sick or hurt overseas Cost of medications and immunizations Are there any other concerns that you have that were not discussed on this form? (Please specify)
