Travel Details

THE TRAVEL DOCTOR

YOUR DETAILS

Last Name	First Name
D.O.B.	Country of Birth
Contact Address: Street	Suburb
State	Postcode
Phone (Home)	Phone (Work)
Email	Mobile
Occupation	Employer
Medicare Number	Nationality
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 travelled to developing countries before? yes no

Did you have any health problems while away? yes no

Do you OR have you had any of these medical problems:

asthma	chronic lung disease	tendency for chest infections	diabetes
high blood pressure	stomach ulcer	heart disease	joint problems
psoriasis	splenectomy	epilepsy	depression
schizophrenia	mental illness	anxiety/panic attacks	irregular heart beat
blood clotting disorders	weakness of the immune system	HIV/AIDS	mastectomy
venous thrombosis	thymectomy

Any other medical problems

Do you have a family history of a blood clotting disorder, clots in the veins or lungs (pulmonary embolus? yes no

Have you been hospitalised in the last 6 weeks? yes no

Have you ever had the disease Hepatitis A (Yellow Jaundice)? 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)

Are you allergic to any of these

eggs	bee stings	sulphur drugs	penicillin
iodine	latex	bandaids	neomycin

Do you have any other allergies?

Have you ever felt faint for fainted after an injection or giving blood 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

Did you miss any of the usual childhood vaccinations yes no

Please outline any particular health concerns regarding this trip.

YOUR TRIP

List Dates for: Leaving this city Leaving this country Returning to this country

Place of Departure from this country(i.e. the country you are in now)

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

How did you learn of this travel doctor? Friend/relative Work colleague Yellow Pages White Pages

Travel Agent (please name) Doctor (please name)

Been to this Travel Doctor before Been to another Travel Doctor before

What date is your appointment with the Travel Doctor