Texas Tech University

International Travel Health Questionnaire

Please enter the dates you will be traveling
Please list your height in feet and inches. For example, 5'3"
Please list your weight in lbs.
Do you exercise? If so, please list the number of times per week that you exercise.
Please describe your tobacco use/types of tobacco used.
IF you are a tobacco user please write the amount of tobacco used on a daily basis. If you are not a tobacco user, please simply state "I do not use tobacco"
How many times in the past year have you used an illegal drug?
If you have used an illegal drug in the past year, please indicate which illegal drug(s).
How many times in the past year have you used a prescription medication for non medical reasons (including taking them for reasons other than prescribed, doses other than prescribed, or prescription medications that were not prescribed to you)?
If you have used a prescription medication for non medical reasons in the past year, please indicate which prescription medication(s).
How often did you have a drink containing alcohol in the past year?
How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?
How often did you have six or more drinks on one occasion in the past year?
Have you ever been hospitalized? If yes, please list dates and give a brief explanation.
Have you had surgery or a serious injury? If yes, please list surgeries and/or injuries with dates.
Do you take and over-the-counter or prescription medications? If yes, please list with the medical condition treated and dosage. This can include herbals, vitamins, and nutritional supplements.
Do you have any allergies to medications? If yes, please list and describe reaction.
Are you or could you possible be pregnant?
What contraception or cycle regulation methods do you use? Check all that apply
Where will you be traveling/visiting/staying? Mark all that apply.
If you selected "other" in the previous question, please describe.
Will you be working with animals?
Do you have any food allergies? If yes, please list the food to which you are allergic.
Do you have any surgical procedures scheduled between now and your date of travel? If yes, please explain.
Are you currently suffering from any mental health condition (e.g. depression, anxiety, drug/alcohol issues, etc.)? If yes, please explain.
Are you currently being treated for any mental health condition (e.g. depression, anxiety, drug/alcohol issues, etc.)? If yes, please explain.
Have you been diagnosed with any of the following medical conditions? Select all that apply. If yes, please explain.
Do your have a family history of any medical conditions? Please reference list above and list all that apply and describe conditions for each impacted family member.
Captcha Verification
 

Student Health Services