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Name: ___
Date of Birth: ___ /___ /___
Date: ___ /___ /___International Travel Questionnaire
Please complete this form prior to being seen for your appointment.
The answers you supply in this questionnaire
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How to fill out travel clinic form
How to fill out travel clinic form
01
Obtain the travel clinic form from your healthcare provider or travel clinic.
02
Fill out your personal information such as name, date of birth, address, and contact information.
03
Provide your travel itinerary including destination, dates of travel, and purpose of trip.
04
List any pre-existing medical conditions or allergies.
05
Indicate any medications you are currently taking.
06
Sign and date the form to certify that all information provided is accurate.
Who needs travel clinic form?
01
Individuals who are planning to travel to foreign countries where certain vaccinations or medical precautions are recommended or required.
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What is travel clinic form?
A travel clinic form is a document used to collect information about an individual's travel history and health status to provide necessary vaccinations and health advice for travel.
Who is required to file travel clinic form?
Travelers who are seeking vaccinations or health advice from a travel clinic are typically required to fill out the travel clinic form.
How to fill out travel clinic form?
To fill out a travel clinic form, provide personal information such as name, contact details, vaccination history, travel destinations, and any current health issues or allergies.
What is the purpose of travel clinic form?
The purpose of the travel clinic form is to ensure that travelers receive appropriate vaccinations and health recommendations based on their travel plans and health history.
What information must be reported on travel clinic form?
The form typically requires information such as personal identification, travel itinerary, vaccination status, medical history, and any existing medications.
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