Travel Health Form Page 2
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3Allergies
List ALL allergies (including medications, food, bees, etc.), the type of reaction/severity, treatment and date of last reaction.
Allergies
Reaction/ Severity
Treatment
Date of last Reaction
Comments:
Do you suffer from Anaphylaxis?* Yes
No
*A severe allergic reaction marked by swelling of the throat or tongue, hives, and trouble breathing.
Do you carry an Epipen? Yes
No
Do you carry an inhaler? Yes
No
Medications
List any medications you are currently taking including dosage schedule and specific instructions for use. Prescriptions must
be in the original container with appropriate label. Please provide extra written prescription(s) from the doctor with the generic
name for all medications in case the original prescription is lost or a new one needs to be obtained.
Other:
Special considerations or notes:
Additional Medical/Dietary Information
Do you have a Special Medical or Dietary Regiment to be followed?
Yes
No
If so, please explain:
Have you ever had any adverse reactions to general anesthetics?
Yes
No
If so, please explain:
Any other information not covered in this form that is important that advisors for this trip should know about - use additional
sheet if necessary?
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Parent category: Business