International Travel Consultation Record
After completing the information below, simply click the [Submit Form] tab. Your
information will be reviewed; and you will then be contacted with the needed
immunizations for your travel destination.

Certain health conditions can dramatically increase a traveler's risk. If you are
pregnant or have a chronic medical condition (i.e. allergies, asthma, diabetes,
epilepsy, cardiac problems, HIV infection, etc.) be sure to note that in the Special
Medical History /Medication section..
CONTACT INFORMATION
Contact Person:
Mailing Address:
City:
State:
Zip:
Telephone #1:
(123) 456-7890
Telephone #2:
Email:
Your email will not be
shared. It will only be
used to contact you
with any questions.
Re-Enter Email:
TRAVELER MEDICAL INFORMATION
Name of Traveler:
Age:
Does this traveler have any chronic medical problems?
Yes
No
If yes, please list:
Yes
No
Does this traveler take any prescription medications?
If yes, please list:
ITINERARY
List of COUNTRIES in order of visit:
U.S. to:
Purpose of travel:
Pleasure
Business
Missionary
Other - please specify:
Comments:
If you should have any questions or concerns,
please
e-mail Shelley Yoder, RN, Director of Clinical Services.
MCHD Home                   International Travel                International Travel Diseases                   International Travel Insects
NOTE: This is a service for Marion County, Illinois,
and surrounding counties only.