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Travel Vaccine Planner

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					                                       Travel Vaccine Planner

It is the responsibility of the traveler to bring his/her childhood and adult immunization/yellow immunization
record to the first travel appointment.


Contact While Traveling-someone who will know how to contact you during travel

Name: ________________________

Address: ______________________

_____________________________

Phone: ________________________

E-mail: ________________________



Travel History
Have you traveled in the past? □Yes □ No
If yes, to what countries?
Year         Countries




Did you encounter any difficulties?
□Travelers’ Diarrhea
□ Altitude Sickness
□ Jet Lag
□ Air Sickness
□ Malaria
□ Other, please explain.


Your Email address_______________________________
□ I will have access to my email while traveling
□ I will not have access to my email while traveling




Updated: 3/7/06
Departure date:_____________________               Return date:_________________________
List all the countries on your itinerary in the order you will be visiting:



Visiting areas outside major cities?

Health History:
History of: Immune Disorders
              Hepatitis Disease A
                                 B
                                 C
Chronic illnesses or major surgeries, for example: asthma, diabetes, seizure disorder, liver or
kidney disease, cancer, high blood pressure, spleenectomy, bleeding disorders, coronary bypass,
                                                    If yes, list.




Have you ever had a TB test?  Yes  No If yes, when?________________
Was there a reaction?             Yes  No If yes, how large? ___________mm.
If yes, did you have a chest x-ray done after the reactive PPD?  Yes  No
What were the results of the x-ray? ______________
Did you take medication after the reactive PPD?  Yes  No
If yes, what medicine and for how long? _________________________________.

Allergies to:                          Other Allergies to Food and Drugs
Thimerosol                             ______________________________________
Insects
Neomycin                               ______________________________________
Yeast
Eggs                                   ______________________________________

Current Medications, including over-
the-counter medications and supplements

__________________________                  Females only:
                                            First day of last menstrual period ___________
__________________________                  Are you pregnant now?
                                            Are you breastfeeding now?
__________________________

__________________________
Immunization Work Sheet – Information from Immunization Records or Yellow book
Routine Vaccines                 General Recommendations                     Dates
Tetanus/Diphtheria or Tdap       Every 10 years                              Last dose:
(Tetanus/Diphtheria/Pertussis)
MMR                              Two doses after the age of 1 or born        #1
(Measles, Mumps, Rubella)        before 1957 or history of diseases          #2
Varicella (Chicken pox)          History of disease OR one dose of vaccine
                                 if given before 13th birthday OR two
                                 doses if given after 13th birthday
Polio                            Childhood series of at least 3 doses
                                 Adult booster for some travelers
Hepatitis B                      Series of 3 doses
Influenza                        Given yearly
Travel Vaccines                  Date(s) Given
Hepatitis A (series of 2)
Typhoid                          oral or injectable?
Rabies
Meningoccocal                    Menomune or Menactra?
Yellow Fever
Japanese Encephalitis
Twinrix (Hep A/B)

Vaccines/Medications to be considered: Recommendations vary by country- Check web site.
Vaccine                              Request     Maybe     Questions for the travel provider:
Tetanus/Diphtheria or Tdap
MMR (Measles, Mumps, Rubella)
Varicella
Polio
Hepatitis A
Hepatitis B
Twinrix (Hep A/B)
Typhoid
Rabies
Meningoccocal
Yellow Fever
Influenza
Japanese Encephalitis
Malaria Prophylaxis
Traveler’s Diarrhea Treatment

				
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