Insight Adventures Traveler Information and Health Form

Personal Traveler Information YOUR NAME: Address: City: Day Phone: Email: Passport Information Full Legal Name (as it appears on Passport): Passport Number: Expiration Date: Birth Place: Nationality: Emergency Contact Information of Traveler Please give us the name of an emergency contact person not traveling with you. Name of Contact: Relationship: Daytime Phone: Other/Evening Phone: Issue Date: State: Zip: Other/Evening Phone:

Flight Information (Please email/forward all Airline E-ticket Itinerary Confirmation to: alexandria.zech@gmail.com) *Arrival Airline : Arrival Date: *Departure Airline: Departure Date: Flight Number: Arrival Time: Flight Number: Departure Time:

Insight Adventures Traveler Information and Health Form

Travel Insurance Travel Insurance Company Name: Travel Insurance Policy Number: Travel Insurance Contact Number: __________________________________ (International Number) Did you purchase Medical and Emergency EVAC Coverage? YES________ Declined________ Did you purchase Trip Cancellation Coverage? YES_________ Declined________

Personal HEALTH Information Name: Male: Female:

Date Of Birth: (Day/Month/Year)

List the medications you are now taking:

List any allergies you have to drugs, food or other items:

Any current health problems ? Are you currently under medical care? If yes, please explain:

Current Immunizations:

Insight Adventures Traveler Information and Health Form

Medical History
Please check if you have or had any of the conditions listed below: High blood pressure: Stroke: Cancer: Emphysema: Ulcers: Mental Illness: ______ ______ ______ ______ ______ ______ Kidney Disease: Bleeding Tendencies: Seizures: Heart Disease: Sugar Diabetes: ______ ______ ______ ______ ______ Asthma: Tuberculosis: Colitis: Anemia: Gout: ______ ______ ______ ______ ______

Please list any other Serious Illness:

Your Primary Care Physician: ( Please list all relevant doctors)

Name: Address: Phone: