Rev. 2/2018
Travel History
Client # ______________ Date: _______________
Name: ________________________________________________ Date of Birth: ___________________
Address: ________________________________________________________________________________
Street City State Zip Code
Home Phone: _____________________________ Work Phone: _________________________________
SSN: __________________ Marital Status: _________________ Race: ___________ Sex: ________
I wish to be consulted (initial your choice) alone ______ with spouse ______ with other ______
Medical History
Allergies to medication, vaccines or food: _______________________________________________________
Do you have any medical problems that warrant medications or physician follow up? Y N
If yes, what: _______________________________________________________________________________
Medications currently taking: _________________________________________________________________
_________________________________________________________________________________________
Do you now of have you ever had:
Heart abnormality Y N Seizure or epilepsy Y N Psoriasis Y N
Psychiatric disorder/anxiety/history of depression Y N Retinopathy Y N
If yes to any, please describe: ________________________________________________________________
_________________________________________________________________________________________
Are you now or might you become pregnant on your trip? Y N Breastfeeding? Y N
Have you ever had a positive PPD (tuberculin skin test) or the BCG vaccine? Y N
Travel Itinerary
Cruise Ship? Y N Name of ship: _____________________________________________________
Purpose of Trip:
Leisure Missionary Business Urban Rural Other
Please list, in order, the places/countries where you will be traveling. Include dates of departure and arrival.
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Are you a frequent traveler? Y N Comments: __________________________________________
How did you hear about us? __________________________________________________________________
____________________________________ _____________________
Client Signature Date
____________________________________ _____________________
Nurse Signature Date
Macon-Bibb County Health Department
Travel Clinic
171 Emery Hwy., Macon, GA 31201
Phone: 478-749-0145
Fax: 478-749-0101
NCHD52.org/Travel
