The World Traveller's Medical Guideline - Activity Sheet 5
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Have you remembered vaccinations? You must check out if you need any and allow enough time for these to be administered. Your medical record is also invaluable should anything go wrong. A simple guideline will help the person giving you medical assistance, as you may not be able to remember everything due to shock or other circumstances. Print this medical form or make your own and keep it in your wallet or with your other important travelling documents.

 

My Name:

My Address:

 

My Phone numbers:

Home: Work: Cellular:
My Date of Birth: My Birthplace:

My Sex:

My Health Insurance:

Name:

Address:

Group Number: Subscriber Number:

My Doctor

Name:

Phone Number:

Address:

 

My Current Medications:

1 3
2 4

 

My Medication Allergies:

 

My Food Allergies:

 

My Other Allergies:

 

My Previous Illnesses / Surgeries and dates

1

2

3

My Immunisations and date given:

1

3

4

My Medication Record:

Medication Name:

Medical Condition:

Start Date:

End Date:

Dosage:

Results:

Reaction/Side Effects:

 

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