Medical Specialists of Central Kentucky
THE TRAVELER HEALTH HISTORY
Name_____________________________________Age_____ Date___________
Travel Destination(s)_________________________________________________
Traveling Dates: Leaving Date_______________ Return Date________________
Food Source: Natives/locals____ Bringing own____ Resort or Hotel____
Water Source: Naties/Local____ Bringing own____ Resort or Hotel____
Purpose of Trip: Pleasure___ Missionary team___ Work___ Medical care____ Study___
Other_______________________________________________________
Traveling with: Family___ Children___ Other adults___ Alone___
Other exposures: ___Rainforest ___Unsanitized Water ___Animals ___Fowl
Medical History: Seizures__ Migraine Headaches___ Altitude Sickness___ Heart problems___
Lung problems___ Depression___ Stomach problems___
Blood disorders_____ Other________________________________________
Allergies (please list) ___________________________________________________________
Medications: _________________________________________________________________
Social History: __Smoker ___Alcohol 2x a week or more? ___Recreational Drugs
Family History: Diseases on your mother's side_______________________________________
Diseases on your fathers's side________________________________________
ROS: Circle any current problems you are having:
headaches, shortness of breath, cough, visual problems, hearing problems, ringing in your ears,
coughing up blood, fatigue, abdominal pain, diarrhea, nausea, vomiting, joint swelling or pains,
other___________________________________________________________________
Hospitalizations (please list)_______________________________________________________
Surgeries (please list):____________________________________________________________
Current medical problems (please list):_______________________________________________
VACCINATION HISTORY: