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Pre-travel pre-consultation form

Pre-travel pre-consultation form
First
Last
Gender
Do you have travel insurance for this trip?
Does this cover: Healthcare overseas?
Does this cover: Medical evacuation?

Travel Plans

Purpose of trip (choose all that apply)

Vaccination history

Will you be visiting areas that are?
Rural
Will you be visiting areas that are?
Urban
Will you be visiting areas that are?
Primitive or remote

Activities

Will you be engaging in any of the following? (choose all that apply)
Accommodation (choose all that apply)

Countries and cities in order of visit (add extra lines as needed)

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Vaccination history

Have you had an adverse reaction to an immunisation?
Did you miss any childhood immunisations?
Have you received the following?
Hepatitis A
Hepatitis B
Meningococcal
Measles/Mumps/Rubella
Polio
Tetanus
Typhoid
Yellow Fever
Japanese Encephalitis
Influenza

Other Vacatcinations (add more as required)

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General health information

Do you have any allergies (foods, medicines)?
Are you or your partner pregnant or intending to become pregnant?
Are you breastfeeding?

Please check health conditions & medications (including OTC) with health provider & ask for a print out to take with you