Information Form

TRAVEL
 SEEKERS

 

 

                            Prefix          

 

                            First Name 

 

                            Last Name   

 

                           Address      

               

                           City              

 

 

                         

                          State 

                                   

                        Zip   

 

                    Phone Number  
Vacation Choice 

Traveler Profile

Date of Birth   
Gender            
Height:              Feet    Inches  
Weight             
Please Answer Yes or No to the Following Questions

Handles Own Money                         

Consumes Alcoholic Beverages     

Verbal                                                 

Wears Glasses                                  

Uses Sign Language                        

Wears Hearing Aid                           

Gets Overheated Easily                   

Uses a Wheelchair                           

Requires Assistance With ADL's   

Wears Dentures                               

Can Walk Long Distances              

Past Eating Disorder                       

 

Needs Assistance Toileting            

Wears Diapers                                 

Describe Any Dietary Limitations  

Behavioral Issues                             

 

Physical Challenges                        

 

Favorite Meals                                 

Bathing Preference                          
Allergies                                            
Medication                                        

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TS
Travel Service

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