About this template
A medical declaration form is an essential tool for collecting health status information, travel history, and symptom checks from travelers, event attendees, or visitors entering restricted facilities. This document helps organizations, transportation providers, and public health coordinators screen individuals efficiently, mitigate health risks, and maintain compliance with safety regulations.
This template streamlines the collection of critical data, including recent travel routes, exposure history, current symptoms, and temperature readings. By gathering this information prior to arrival or boarding, organizers can quickly identify potential health risks, determine who requires further medical evaluation, and support necessary contact tracing efforts.
Doc2Form allows you to instantly convert this template into a ready-to-use Google Form, making it simple to share via a secure link or QR code. Respondents can complete the assessment quickly on any device, while all submissions route directly into your Google Sheets for seamless tracking, review, and record-keeping.
Key features
- Collect detailed symptom and exposure history in minutes.
- Track travel routes, flight details, and destination addresses.
- Easily review submissions organized neatly in Google Sheets.
- Share via secure link or QR code for rapid mobile completion.
- Fully customizable to match your organization's specific screening criteria.
Use cases
- Screening international or domestic travelers prior to boarding.
- Health and safety clearance for large corporate events and conferences.
- Visitor access logging for secure facilities and office buildings.
- Initial health intake for group tours and travel agency clients.
What this form collects
- Full Name (Short answer)Enter your first and last name as shown on your official ID or passport.
- Email Address (Short answer)Provide a reliable email where we can send your health clearance or follow-up communications.
- Phone Number (Short answer)Include your country code and area code.
- Birthdate (Date)Select your date of birth.
- Gender (Multiple choice)Select your gender identity.
- Airport or Terminal of Origin (Short answer)Enter the name of the airport or terminal where your journey began.
- Date of Arrival (Date)Select your scheduled arrival date.
- Airline (Short answer)Enter the name of the airline operating your flight.
- Flight Number (Short answer)E.g. UA123 or DL456.
- Seat Number (Short answer)Enter your assigned seat number.
- Destination Address (Paragraph)Enter the address where you will be staying during your visit.
- Countries Visited in the Past 14 Days (Paragraph)List all countries or regions you have traveled to or transited through recently.
- Symptom Status in the Past 24 Hours (Checkboxes)Select any symptoms you have experienced recently.
- Current Temperature Reading (Short answer)Enter your latest measured temperature (e.g., 98.6°F or 37°C).
- Do you currently appear or feel unwell? (Multiple choice)Select your current general health assessment.
- Health Clearance Status (Dropdown)For official use: Select clearance determination.
- Screener Full Name (Short answer)If reviewed by staff, enter the screener's name.
- Date of Submission (Date)Select today's date.
FAQ
Why is a medical declaration form used?
It is used to collect vital health information and travel history from individuals to ensure compliance with health regulations, screen for potential contagious risks, and maintain a safe environment.
What information does this form collect?
The form captures basic personal details, recent travel history, flight or transit numbers, recent symptom statuses, and current temperature readings.
How do I share this form with respondents?
Once you convert this template into a Google Form using Doc2Form, you can share it via email, embed it on a website, or display it as a QR code at your entrance or check-in desk.
Can I customize the questions on this template?
Yes! Because the template lives in your Google Drive as a standard Google Form, you can easily add, remove, or modify questions to suit your specific health and safety requirements.
Where are the submitted responses stored?
All responses are automatically saved in a secure Google Sheet connected to your form, allowing you to review data in real-time and export records as needed.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.