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Microsoft word - pretravel assessment form may 2010.doc

Pre - travel assessment form (Please complete and return to Receptionist)

Mr / Mrs / Ms / Dr Surname …………………………………… First name ….………………………
Date of birth …. / …. / …. Occupation ………………… This trip is for holiday / business requirement
Contact details for the next 1- 2 years: MOBILE phone ….…………………… Daytime phone ……….………………
Address ……………………………………………………………………………………………… Postcode ………………. Email: …………………………………………………. I heard about The Travel Clinic from: Google / Yellow Pages / White Pages / friend / Travel agent / GP / other ……… Travel Agent (name & address) ….……………………………………………………………….………………………………. Please inform my GP about about vaccinations given here (insert name and address of GP here): GP (name and address) ….………………….……………………………………………………………………….…………. I will pay by Cash / EFTPOS/ Visa / Mastercard /. I have Private Health Extras Cover? Yes / No
My date of departure is
…. / …. / …. My date of return is …. / …. / …… I will visit the following countries:
Country (in order of visit)
Duration (weeks)
Accommodation (hotel / tent / backpack)
Cities only

Please list countries you have visited previously: …………………………………………………………………………….
Have you ever fainted or felt unwell soon after an injection ? ……. Could you be pregnant while away? (Females only) . Does someone with lowered immunity live at home with you ? Are you allergic to eggs, medications or other substances? .
Please list these allergies: .……………………………………………………………………………………………………….

Please list ALL medications you are currently taking: …………………………………………………………………………….

Please list past significant medical / health problems you have had both here and overseas. Especially note past history of
jaundice, hepatitis, deep vein thrombosis (DVT) or blood clots, ear or hearing problems or have a disease which lowers
immunity (eg cancer, HIV/AIDS, thymus disorder).
…………………………………………………………………………………………………………………………………………….
* In order to avoid unnecessary vaccinations along with extra charges, you need to complete the following table
before your appointment.
Please put the approximate year you had any of the following vaccines or diseases, including,
measles, mumps, rubella, chicken pox as well as the date of your last tetanus vaccine. You can check with your GP or
previous medical records to find this information.

Vaccine given
Vaccine given
Vaccine given
Would you like us to email you our quarterly travel health newsletter ‘Take Care’? Yes
Would you like information on medical kits for travellers to prevent illness? . Yes
Vaccinations, medications and kits
Fluvax / Influvac/Jnr Panvax /
Vaxigrip / Intanza
Gardasil
(Avaxim / VAQTA / Havrix / Jnr) Hepatitis B (HBVax/Engerix) Neisvac C/Meningitec/Menjugate Pneumococcal MIRV / Verorab / Rabipur Typhoid Typhim Vi / Typherix Vivotif Oral 3 / 4 / Vivaxim Yellow fever (Stamaril) 2. Malaria tablets
3. Kits / other item
Dr’s signature
(Dr's signature certifies discussion of risks and benefits of vaccines and medications with patient)
Circled item number indicates medicare level as per practice manual description
Notes:
Checklist:
‰ Yellow fever certificate stamped
‰ Pocket guide entered
‰ Report given
‰ Referral source & country entered
‰ Copy to GP / Travel agent / pads
‰ Recalls entered

Source: http://www.breedstclinic.com.au/uploads/downloads/travel.pdf

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