Step 1 of 5

20%

Name*

First Last

Today's Date*

MM slash DD slash YYYY

Date of Birth*

MM slash DD slash YYYY

Gender*

Male

Female

Prefer Not to Answer

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Best Time to Call*

Morning

Afternoon

Evening

Email*

Health Care Provider's Name*

First Last

Clinic Name*

City/Town of Clinic*

Do you have a current passport or visa?*

Yes

I don’t know

Purpose of Trip*

School Related Study/Work

Pleasure

Business

Aid/Refugee Work

Other

What will you be doing on this trip?*

Does your program require the completion of a medical form by a practicioner?*

Yes

Not Sure

Are you currently enrolled in a health insurance company that covers you while overseas?*

Yes

Not Sure

What insurance coverage do you currently have?*

Do you have medical evacuation insurance?*

Yes

Not Sure

Departure date from the United States*

MM slash DD slash YYYY

Return Date to the United States*

MM slash DD slash YYYY

Please list the countries AND cities to be visited in order of visits, along with the arrival and departure dates.

City

Region

Country

Arrival Date

Departure Date

Have you traveled outside the United States before?*

Yes

If yes, where and when?

Will you be:

Visiting ONLY major cities?*

Yes

If no, explain:

Staying ONLY in hotels?*

Yes

If no, explain:

Staying with friends and family?*

Yes

Ascending to high altitudes (>7000 ft. or 2300m) in the mountains?*

Yes

Working in the medical or dental field with exposure to blood or other bodily fluids?*

Yes

Working with exposure to animals?*

Yes

Potentially having sexual contact with new partners?*

Yes

Are you an adventurous eater?*

Yes

Do you have known food or drug allergies?*

Yes

Please list any known food or drug allergies.

Have you had an allergic reaction to any of the following? (check all that apply)*

Eggs

Antibiotics (eg: Neomycin, Streptomycin, Ciprofloxacin [Cipro], Levofloxacin [Levaquin], Azithromycin [Zithromax])

Sulfa Drugs (eg: Bactrim, Septra, Gantrisin)

Tetracyclines (Doxycycline, Minocycline [Minocin], Tetracycline [Achromycin, Sumycin])

Thimerosal (preservative in contact lens solution)

Latex

Quinolines (Chloroquine [Aralen], Mefloquine [Lariam], Hydroxycholoroquine [Plaquenil], Primaquine)

Baker’s Yeast

Chrysanthemums

Pyrimethamine

None

Other

Please list other allergic reactions.

Were you born in the United States?*

Yes

If no, where?

Have you completed the following immunizations? (Please bring your vaccination record)

Haemophilus B*

Yes

Not Sure

If yes, when?:

Herpes Zoster (shingles)*

Yes

Not Sure

If yes, when?:

Hepatitis A*

Yes

Not Sure

If yes, when for #1?:

If yes, when for #2?:

Hepatitis B*

Yes

Not Sure

If yes, when for #1?:

If yes, when for #2?:

If yes, when for #3?:

HPV (human papilomavirus)*

Yes

Not Sure

If yes, when?:

Influenza (flu shot)*

Yes

Not Sure

If yes, when?:

Japanese Encephalitis*

Yes

Not Sure

If yes, when?:

Meningococcal Meningitis*

Yes

Not Sure

If yes, when?:

MMR (Measles, Mumps, Rubella)*

Yes

Not Sure

If yes, when?:

Pneumococcal (pneumonia)*

Yes

Not Sure

If yes, when?:

Pertussis (whooping cough)*

Yes

Not Sure

If yes, when?:

Polio Series*

Yes

Not Sure

If yes, when?:

Rabies*

Yes

Not Sure

If yes, when?:

Rotavirus*

Yes

Not Sure

If yes, when?:

Tetanus/diphtheria*

Yes

Not Sure

If yes, when was your last booster?:

Typhoid Fever*

Yes

Not Sure

If yes, when?:

Varicella (chicken pox)*

Yes

Not Sure

If yes, when?:

Yellow Fever*

Yes

Not Sure

If yes, when?:

Are you taking steroids, receiving radiation therapy or other immunosuppressive therapy?*

Yes

Are you currently taking any prescription medications? (Including birth control pills and acid blockers)*

Yes

List your current prescription medications (include birth control pills and acid blockers)*

Are you currently taking any non-prescription medications? (Over-the-counter, herbal, homeopathic, vitamins, etc.)*

Yes

List regularly used non-prescription medications (over-the-counter, herbal, homeopathic, vitamins, etc.)*

Have you been told you have any of the following medical conditions (check all that apply)?

Anemia*

Yes

Family History

Asthma*

Yes

Family History

Blood Clotting Problems*

Yes

Family History

Cancer*

Yes

Family History

Depression*

Yes

Family History

Diabetes*

Yes

Family History

Ear Infections/Chronic of Frequent*

Yes

Family History

Epilepsy/Seizure Disorder*

Yes

Family History

Eye Problems*

Yes

Family History

G6PD Deficiency*

Yes

Family History

Gout*

Yes

Family History

Hearing Problems*

Yes

Family History

Heart Disease*

Yes

Family History

High Blood Pressure*

Yes

Family History

High Cholesterol*

Yes

Family History

Hormone Problems*

Yes

Family History

Immune System Deficiency*

Yes

Family History

Kidney Disease*

Yes

Family History

Liver Disease/Hepatitis*

Yes

Family History

Lung Disease*

Yes

Family History

Prostate Problems*

Yes

Family History

Psoriasis/Other Skin Problems*

Yes

Family History

Psychiatric Concerns*

Yes

Family History

Sickle Cell Disease*

Yes

Family History

Stomach Ulcer*

Yes

Family History

Stroke*

Yes

Family History

Thymus Problems*

Yes

Family History

Other*

Yes

Family History

**Please list below any other medical histories

**Other:

Date of last normal menstrual period*

MM slash DD slash YYYY

Are you or could you possibly be pregnant?*

Yes

Are you breast-feeding an infant?*

Yes

Please list additional questions or concerns you might have regarding your travel*

How did you hear about us?*

Forward Pharmacy can offer you tips to keep you safe and healthy while traveling abroad. Please check any of the following topics you would like to receive more information on to help you prepare for your trip.

Air Travel

Altitude Sickness

Basic Preventative Measures (Insect precautions, safe food and water, safety and crime avoidance, etc.)

Children & Travel

Country Profiles (Entry requirements, health concerns, medical care, travel advisory)

Cruise Ship Travel

Diabetic Travelers

Disabled Travelers

Food & Beverage Precautions

Hajj Travelers

Health Care Abroad

Immunization Requirements & Recommendations

Local Regulations

Malaria Information

Marine Hazards

Motion Sickness

Packing a Medical Kit

Passports and Visas

Pregnant Travelers

Preparation for Emergencies (checklist of things to do before you leave)

Pulmonary Disease & Travel

Safety & Security

Stomach Disorders & Travel

Traveler’s Diarrhea Information (Transmission, risk factors, symptoms, prevention, treatment)

Traveler’s Thrombosis

Other

Please list other topic(s).

Safe Travels Information Form

Travel History Form

Will you be:

Have you completed the following immunizations? (Please bring your vaccination record)

Have you been told you have any of the following medical conditions (check all that apply)?