Mount Holyoke College :: Travel Medicine & Immunization Service

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Travel Medicine and Immunization Service

In order to provide for the best use of the time allotted in your travel medicine appointment, please complete and submit the following information 48 hours in advance of your appointment. Thank you! Health History and Travel Itinerary:

* = Required fields

	Travelers Information
*	Traveler's Name (first, last)

	Class Year

*	Traveler's email address:

	Medical History:
	Chronic Illnesses Check those that apply to yourself or to a close contact, such as a roommate or immediate family member.
	Cancer Lymphoma Leukemia Immune Deficiency
	Other Chronic Illnesses Only check those that apply to you.
	Ulcer Asthma Diabetes Seizure Disorder
	Other

	Major Surgery
	Gastrectomy Ulcer Splenectomy
	Other

	Medications On this item, check any that apply to yourself or a close contact.
	Steroids Immunosuppressants Chemotherapy
	On this next set, check only those which apply to yourself.
	Antacids, inc: Zantac, Tagamet, Pepcid
	Other

	Allergies
	Aspirin Eggs Serum or Vaccine Sulfa Penicillin
	Other

	Prior Travel Immunizations Received Bring yellow vaccination record to your appointment if possible.
	Hepatitis A Yellow Fever Typhoid
	Other

*	Do you have any physical limitations?

*	Do you have any history of psychiatric problems?

	Other Health Information

	Travel Itinerary:
*	Departure date (mm/dd/year):

	For the following, please include country, region and town if known:
*	Originating from:
*	1. To
*	- Length of stay (specify days or weeks) ,
	2. then to:
	- Length of stay (specify days or weeks) ,
	3. then to:
	- Length of stay (specify days or weeks) ,
	4. then to:
	- Length of stay (specify days or weeks) ,
	5. then to:
	- Length of stay (specify days or weeks) ,
*	Returning to:
*	Return date (mm/dd/year):
	Mode of transportation:

*	Will you travel to rural or outlying areas?

	Will you stay with a host family?

	Do you expect to work with animals?

*	Will you work in a health care capacity or be likely to come into contact with blood or body fluids?

	Do you plan any high altitude climbing or trekking?

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To contact the College, call 413-538-2000.
This page maintained by Health Services. Last modified on September 10, 2007.