Post Travel Information

Please fill out this form as completely as possible. Also, bring your medications to your appointment.

If you have any questions, please call the Travel Clinic at 801-581-2898.

Patient Name: ^*

Date Of Birth: ^*

Marital Status:

Preferred Language: ^*

Occupation: ^*

Employer: ^*

Reason for this Visit:

Travel History: Places You Have Lived Or Traveled: ^*

Have You Had Contact With Pets Or Animals?: ^*

Past Medical Problems: Please Include Dates: ^*

Hospitalizations And Surgeries: Please Include Dates: ^*

Medications You Are Taking Now: Type, Dose, And Time Of Day: ^*

Drug Allergies: ^*

Referring Physician Name: ^*

Phone Number: ^*

Address: ^*