Travel History Form
Complete this form to request a travel consultation OR prior to your scheduled travel consultation at Flathead City-County Health Department
Demographics
Name
*
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Primary Insurance:
*
Back
Next
Travel Plans
List the countries and cities in order of visit with arrival and departure dates
*
City, Country
Arrival Date
Departure Date
1st
2nd
3rd
4th
5th
6th
7th
8th
Purpose of Trip (select all that apply)
*
Vacation
Education/research
Visit family/fridnds
Missionary/volunteer/humanitarian relief
Work (urban, office-based, or conferene)
Other
If "Other" was selected:
Provide a Brief Description of Planned Activities
Indicate if You Will Be:
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
Type of Accommodations
Resort/large hotel
Small hotel/guest house/bed and breakfast
Cruise ship
Private home (with locals or relatives)
Primitive camping
Up-scale camp/lodge
Dormitory/hostel
Health History
Allergies
*
Yes
No
If "Yes" List Allergies
Current medical conditions
*
None
Yes
If "Yes" List Current medical conditions
Medications and Dosage
Name of Medication
Dose
Frequency (Daily, As needed, Weekly etc.)
1
2
3
4
5
Have you received the following Vaccines: (Bring all vaccine records to your appointment)
Yes
No
Not Sure
COVID-19 (this season)
Hepatitis A
Hepatitis B
Influenza (this season)
Japanese Encephalitis
Measles/Mumps/Rubella (MMR)
Meningococcal ACWY
Tetanus
Typhoid
Yellow Fever
Have you ever had a adverse reaction to a vaccine?
Yes
No
If "yes" describe the reaction
Do you have additional questions or concerns about your travel?
Submit
Should be Empty: