TRAVEL HEALTH QUESTIONNAIRE (CHILD)
Name of child:______Date of birth:______Age: ______
Sex: M F
Name of person completing form: ______Relationship to child:______
Heath History For Child
PREGNANCY AND BIRTH:
Hospital: ______City: ______
Type of delivery: ______Length of pregnancy: ______
Problems during pregnancy or labor: ______
Smoking during pregnancy: No Yes packs per day: ______
Alcohol during pregnancy: No Yes describe: ______
Other dugs or medications taken during pregnancy: ______
Baby’s weight at birth: ______
Any probems at birth or in the first two weeks after birth (resuscitation at birth, jaundice requiring treatment, breathing troubles, seizures, low blood sugar, infections, feeding problems, etc…):______
______
Was baby breastfed? No Yes How long: ______
HEALTH HISTORY SINCE BIRTH:
Date of your child’s last complete physical examination: ______
Does your child have a regular doctor? No Yes Name: ______
List any medications your child currently takes on a regular basis, with doses:
______
______
Travel Health Questionnaire (Child) page 2
Please list any allergies your child may have (to medications, specific foods, bee or wasp stings, etc.) or write “none”:______
______
Has your child ever had an allergic reaction to eggs or gelatin? No Yes
Describe: ______
Has your child or anyone in the family ever been diagnosed with G6PD deficiency?
No Yes explain: ______
Has your child ever been diagnosed with HIV infection or any immune deficiency disease?
No Yes explain: ______
Has your child ever been hospitalized? No Yes
DatesReasonHospital
______
______
______
Has your child had any surgeries? No Yes Describe: ______
______
Describe any serious injuries (broken bones, stitches, concussions, poisonings, etc…):
______
Has your child ever had any of the following problems?:
NoYes
anemia
arthritis
asthma
allergies (such as hay fever or severe food allergy)
severe allergic reaction to bee or wasp sting
bleeding or bruising problems
blood diseases, including sickle cell and thalassemia
cancer or leukemia
chicken pox date:______
constipation
ear infections how many?:______
epilepsy or seizures
Travel Health Questionnaire (Child) page 3
NoYes
fainting or dizziness
headaches
hearing problems
heart problems
kidney disease
lead poisoning
leg pains
liver disease
migraines
motion sickness
pneumonia
skin problems
tuberculosis or positive TB skin test
urinary infection (kidney or bladder)
vision problems
wears glasses since what age?:______
Explain any “yes” answers and/or list any additional information that you feel is important:
______
______
______
______
IMMUNIZATIONS: Please bring a copy of your child’s shot record, including any shots given previously for foreign travel.
Please bring form or fax to our office:
James D. Briggs, M.D.
3300 Providence Dr.
B tower, Suite 212
Anchorage, AK 99508
Phone: 907-561-4459
Fax: 907-561-4767