Travel History Form

Travel History Form

Complete this form to request a travel consultation OR prior to your scheduled travel consultation at Flathead City-County Health Department
Have you been seen at FCCHD in the past 10 years?
Demographics
Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Primary Insurance:

Rows	Yes	No	Not Sure
Visiting rural areas
Visiting urban areas
Visiting primitive/remote areas
Ascending high altitudes (8000ft or more)
Potential to be exposed to body fluids (medical/dental work)
Working with exposure to animals

Rows	Name of Medication	Dose	Frequency (Daily, As needed, Weekly etc.)
1
2
3
4
5

Demographics