Travel Health Form Page 3
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3Medical Examination Form:
Must be completed by a licensed physician, nurse practitioner, physician’s assistant or
registered nurse within the preceding 12-24 months, unless a health issue is present.
To be completed by Trip Advisors or Trip Participant:
Trip/Activity:
Region/Location:
Date Range of Trip/Activity:
Distance from Emergency Medical Services:
Level of First Aid Required:
Trip/Activity Description: Include a brief description of your trip. This will help the medical professional evaluate your
.
physical readiness for the trip
Please note if different activities will be done (ex. rock climbing, exploring cultural sites, etc.)
Medical Examination
To be completed by healthcare provider
Height:
Weight:
Blood pressure:
/
Pulse Rate:
Hearing: R
L
Eyes: With Glasses R 20/
L 20/
Without Glasses R 20/
L 20/
Code: S = Satisfactory NS = Not Satisfactory NE = Not Examined
Nose
Abdomen
Urinalysis
Musculoskeletal
Throat
Hernia
HGB
General Emotional State
Teeth
Genitalia
Skin
General Physical State
Heart
Appearance/Nutrition
Other:
Lungs
Record of Immunization
Must be completed in detail, or a copy of a current immunization record may be attached to this form
Date Series
Year of Last
Date Series
Year of Last
Immunization
Immunization
Completed
Booster
Completed
Booster
Hep B
Typhoid
DTap/Tdap
Paratyphoid
DT/Td
Cholera
Hib
Yellow Fever
IPV/OPV
Typhus
PCV7
Rocky Mountain
MMR
Spotted Fever
Varicella
HPV
TIV/LAIV
Rota
Hep A
MCV4/MPSV4
Tuberculin Test:
Year last given: ______________ Result: _______________________________
Physician Information
Licensed Physician Name:
Licensed Physician Name:
Address:_________________________________________ City:___________________ ST:________ Zip:______________
This person is in satisfactory condition and may engage in all usual activities, including physically demanding activities except
as noted.
Signature of Licensed Physician: ____________________________ State License Number: ___________ Date:
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