Travel Health Services Forms

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Please provide as much information as possible so University Health Service can best serve you, and be sure to submit forms promptly so you can schedule an appointment.

Deliver your forms to UHS via:

·  Email to (“med” is required in this email address; email is not secure, may not be read every day, and should not be used for urgent or sensitive issues) OR

·  Deliver printed forms to the UHS 2nd floor Appointment Scheduling window (207 Fletcher St)

Your name - Last: / Click to enter / First: / Click to enter / Birthdate: / Click to enter
Are you traveling with a U-M group? / Yes / If Yes, which one? / Click to enter
Best phone number: / Click to enter

Itinerary – List your primary destination(s), plus any travel before and after that location.

Country, location: / Arrival date: / Departure date: / Accommodations e.g. hotel, camp … / Overnight in rural area?
Ann Arbor, MI / Click
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Current medications and supplements: / Click to enter
Allergies, medical and other: / Click to enter
Chronic medical conditions: / Click to enter

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Your name - Last: / Click to enter / First: / Click to enter / Date of Birth: / Click to enter

This information will be used to determine which immunizations you need and will receive at your clinic visit. Your program may pay for some immunizations and medications. If your program does not pay for all needed immunizations or medications, you would be responsible for payment at time of service.

Your immunization history is:
c Marked below -- who completed this form?
c Student c Other (specify): / Click to enter
c Attached – (be sure to include your name and date of birth on any forms)
c Previously submitted to UHS (note: UHS does not have access to immunization records that you may have given to another other U-M unit)
c Other (specify): / Click to enter

University Health Service, University of Michigan www.uhs.umich.edu/travelhealth Phone 734-764-8320 rev4/11/14

Vaccine / Date Received (m/d/y)
Hepatitis A - Dose 1: / Click
Dose 2: / Click
Dose 3: / Click
Hepatitis A+ B Combination (TWINRIX):
Dose 1: / Click
Dose 2: / Click
Dose 3: / Click
Hepatitis B - Dose 1: / Click
Dose 2: / Click
Dose 3: / Click
Influenza: / Click
Meningitis (Meningococcal):
Initial:  Menactra  Menomune  Menveo
Click
Booster:  Menactra  Menomune  Menveo
Click
Measles, Mumps, Rubella (MMR):
Dose 1: / Click
Dose 2: / Click
Polio -- Primary Series:
Dose 1: / Click
Dose 2: / Click
Dose 3: / Click
Adult Booster: / Click
Vaccine / Date Received (m/d/y)
Tetanus-Diphtheria:
Primary Series: / Click
Booster:  Td  Tdap / Click
Rabies Pre-Exposure:
Dose 1: / Click
Dose 2: / Click
Dose 3: / Click
Typhoid:  Oral  Intramuscular (shot)
Click
Japanese Encephalitis:
Dose 1: / Click
Dose 2: / Click
Yellow Fever:
Dose 1: / Click
Dose 2: / Click
Tuberculosis Test: / Click
Other -- include titers (laboratory evidence of immunity) if relevant:
Click / Click
Click / Click
Click / Click
Click / Click
Click / Click
Click / Click

University Health Service, University of Michigan www.uhs.umich.edu/travelhealth Phone 734-764-8320 rev4/11/14