Pomperaug District Department of Health
PART A
- Travel Clinic Personal and Trip Information
Please submit this form prior to making your
appointment for the travel clinic.
Submit this form via button below
to schedule an appointment.
One form per traveler.
Personal Information
First Name
*
Last Name
*
Gender
*
Male
Female
Age
*
Age:
*
Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
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2012
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1920
Year
Address
*
City
*
State
*
ZIP code
*
Home Phone
*
Cell Phone
E-mail
*
Back
Next
Trip Information
Date of Departure from home
*
-
Month
-
Day
Year
Date
Return Date
-
Month
-
Day
Year
Date
Return Date Unknown
true
Have you traveled internationally in the past?
*
No
Other
Do you intend to travel frequently in the future?
*
Yes
No
Maybe
Itinerary: List ALL countries to be visited, including stopovers, IN THE ORDER TO BE VISITED
*
Is this a fixed itinerary?
Yes
No
Destination
*
Urban
Rural
Remote
High Altitude
Beach
Purpose of trip (check all that apply)
*
Vacation
Medical Care
Business
Education
Adoption
Volunteer/Humanitarian
Long-stay traveler
Visiting friend and/or relative
Other
Organized Tour?
Yes
Other
Accommodations
*
Hotel
Hostel
Staying with locals/friends/family
Rented House/Apt
Camping
Cruise Ship/Boat
Other
Will you be traveling alone?
Yes
Other
Planned Activities (check all that apply)
*
Air Travel
Biking
Hiking
Snorkeling
Swimming
Rafting
Boating
Scuba
Climbing/Trekking
Cave/Spelunking
Contact with animals
Public Transport (bus, train, etc.)
Visiting schools, hospitals, orphanages
Health Care Worker
Occupational exposure
Other
How did you find out about this service?
*
Please Select
Google Search
Press Release
Referral – Word of mouth
Physician Referral
Travel agent
Health District Website
CDC Website
Other
If other, where?
Submit
Should be Empty: