Medical History Form

Travelers should check with a health care provider and family records to complete this information. A copy of this should be carried at all times.


Blood Type/RH Factor:

Allergies to food, insects, medicine, or environmental factors:

Name, address, and telephone of health care provider in home country:

Name, address, and telephone of health care providers or hospitals in destination country:

Chronic conditions (e.g., cardiac problems, diabetes, hypertension):

Current or recent conditions (e.g., pregnancy, influenza, injury):

Prescription for glasses or contact lenses, if relevant:

Dental history, if relevant:

Attach signed, dated letter from a health care provider explaining all current treatments or medications. Include any prescriptions, using both generic and brand names.