Travel Details

THE TRAVEL DOCTOR

RETURNING CLIENTS' FORM

YOUR DETAILS

Last Name	First Name
Please complete the following if there have been any changes in your details since your last visit
Contact Address: Street	Suburb
State	Postcode
Postal Address (if different from above)
Phone (Home)	Phone (Work)
Email	Mobile
Occupation	Employer
Medicare Number
Have your private health insurance details changed?		yes no
If yes, how?
Do you want a copy of your vaccination record sent to your doctor?		yes no
Your doctor's name and address

YOUR HEALTH

Have you been in hospital in the last 6 weeks?

yes no

List any medications you are taking now (e.g. contraceptive pills, antibiotics)

List any medications you occasionally take (e.g. migraine tablets, ventolin, vitamins)

H ave you developed any allergies since your last visit?

yes no

Women only - Could you be pregnant now OR do you plan to become pregnant within 3 month of you return

yes no

Are you in contact with anyone with a weakened immune system? e.g. people with aids, cancer sufferers on chemotherapy, people taking steroid drugs

yes no

Please outline any particular health concerns regarding this trip.

CURRENT TRAVEL PLANS Please complete

List Dates for: Leaving Australia Returning to Australia

What is the main purpose of your trip? Holiday Visiting family/friends Business trip Other

Type of accommodation Camping Budget Air conditioned hotel Private Home Other

Will you be doing any adventure activities Trekking Scuba diving Climbing Other

Who will you be travelling with Solo Organised Tour Another Person/s

Please list in order the countries you intend visiting and how long (in days) you plan to spend in each:

OTHER

What date is your appointment with the Travel Doctor