PRE-TRAVEL HEALTH CHECK

Please fill in the following information to assist us in providing you with the most appropriate Travel Vaccination Advice. Thank You!

Name:

Date of birth:

Destination:

Departure date:

Duration of Trip:

Allergies:

Yes, Please specify

Are you pregnant or planning to become pregnant in the next 3 months?

Yes

Will children be accompanying you?

Yes

If yes, what age(s)?

Regular medications: please specify

50% of travellers will develop an illness while away, have you prepared a gastro kit for your trip? The travel nurse will discuss this with you. Our kits are comprehensive and can be purchased at the consultation.

YOUR TRIP Please tick appropriate boxes

Accommodation:

Camping

Budget

Midrange Hotel

Air Conditioned Hotel

Friends/Family

Possible high risk activities:

Scuba diving

Trekking

High altitudes

Camping

Sleeping in huts

Rocking climbing

Surfing

Contact with animals

Immunisations are the most effective way to prevent illness. Please indicate which vaccines you have had in the past 10 years:

Tetanus YEAR:

Polio YEAR:

Measles/Mumps/
Rubella YEAR:

Hep A YEAR:

Hep B YEAR:

Typhoid YEAR:

Yellow Fever YEAR:

Meningococcal YEAR:

Flu YEAR:

Cholera YEAR:

Other: