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Travel Clinic Checklist

To be completed by student

* Indicates a required field

* Name:

* Email:

* Date of Birth:

* Destinations:

Urban Rural

* Estimated Departure Date:

* Estimated Return Date:

Reason for Travel:
UR Study Abroad Program SSIR Other

Activities Planned:
Hiking/Camping/Outdoor Research
Potential animal exposure
Other

* Are you currently taking any medications? No Yes

* Do you have a history of chronic illness? No Yes

* Do you have any allergies? No Yes

* Is a physical exam required for your program? No Yes
If yes, due date:

I have reviewed the following information:
General travel recommendations per CDC guidelines:
*Safety and risk reduction measures: Injuries and Road Safety, Travel Health Kit
*Illness prevention measures: Food and Water Safety, Traveler’s Diarrhea, Avoiding Bug Bites
*Traveling with medications: Allow 60-90 days to plan prior to travel.  Review resources:  Embassy, CDC website, IAMAT