Overview of Travel Health and Safety
Overview of Travel Health and Safety
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. |
Name:
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Address/Telephone:
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Blood Type/RH Factor:
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Allergies to food, insects, medicine, or environmental factors:
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Name, address, and telephone of health care provider in home country:
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Name, address, and telephone of health care providers or hospitals in destination country:
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Chronic conditions (e.g., cardiac problems, diabetes, hypertension):
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Current or recent conditions (e.g., pregnancy, influenza, injury):
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Prescription for glasses or contact lenses, if relevant:
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Dental history, if relevant:
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Attach signed, dated letter from a health care provider explaining all current treatments or medications. Include any prescriptions, using both generic and brand names.
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