Travel Medicine Questionnaire

June 29, 2011

A travel medical questionnaire is helpful to understand the medical status of persons travelling. This is needed to take appropriate caution and care of the person along with allowing medical tools or medicines to be carried along with the person.
Sample Travel Medicine questionnaire:
Name:       ______________________________
Phone number:   ______________________________
Email address:            ______________________________
Gender:             Male / Female
Age:                  ________________     Date of Birth:      _____________
Home address line1: __________________________________________________
Home address line2: __________________________________________________
City: ___________________ State: ____________________ Zip: ______________
Q1. Tick the diseases for which you have taken immunization. Please mention the dates of immunization alongside.
a)   Hepatitis A  1____________ 2___________ 3_____________
b)   Hepatitis B  1 ____________2 ___________3 _____________
c)   Chicken Pox       _________________
d)   Influenza    _________________
e)   Swine Flu   _________________
f)    Polio          _________________
g)   Tetanus     _________________
Q2. Please mention the diseases that you were affected of in the past (including the ones mentioned above)
_____________________________________________________
Q3. Do you have any medical disorder?
a)   Yes
b)   No
Q4. If the answer to the above question is ‘yes’, please mention the disorder
__________________________________________________________
Q5. Did you ever face seizures?
a)   Yes
b)   No
Q6. If the answer to the above question is ‘yes’, please mention if you still have the same problem and if you have taken medication for the same
___________________________________________________
Q7. If you are female, then tick the right option among the following
a)   I am unmarried
b)   I am married and have kids
c)   I am married and currently pregnant
d)   I am married and planning to have kids
e)   Other ___________________________________________________
Q8. If you are female, are your menstrual cycles regular?
a)   Yes
b)   No
Mention your last menstrual period date __________________________________________

Download Travel Medicine Questionnaire in Word Format

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