Skip to content
Home
Our Fees
Our Services
Flu information 2024
Our Team
Work For Us
Contact Us
Our Newsletters
Menu
Home
Our Fees
Our Services
Flu information 2024
Our Team
Work For Us
Contact Us
Our Newsletters
Enrol With Nelson
Enrol With Titoki
BOOK APPOINTMENT
Travel Medicine Consult Questionnaire
It would helpful if you can complete this questionnaire & send it to us before your consult.
First Name | Ingoa Tuatahi
Last Name | Ingoa whānau
Date of Birth
Age
Address
Contact Phone Numbers
Email Address
Date of Departure
Date of Return
Do you have, or have you ever had any medical problems? (eg: diabetes, splenectomy, immune system disorders, clotting disorders)
Yes
No
Do you take any prescription or non-prescription medications?
Yes
No
Have you had an allergic reaction to anything, including any previous vaccines?
Yes
No
Have you been in hospital, been ill or injured in the past 6 weeks?
Yes
No
Are you currently undergoing any medical investigations or treatment?
Yes
No
Have you had immune globulin or a blood transfusion in the past 12 months?
Yes
No
Are you up to date with your childhood/routine vaccinations?
Yes
No
Have you travelled internationally before & have you had any previous travel vaccinations?
Yes
No
Women only: Are you pregnant, contemplating pregnancy while traveling, or within three months of your return?
Yes
No
Please list in order, the countries you intend visiting & how long you plan to spend in each country:
What is the main purpose of your trip?
Holiday
Visiting Family/Friends
Business
Other (please state)
What is the main purpose of your trip? Other please state
Type of Accommodation?
Hotel
Budget
Camping
Private Home
Other (please state)
Type of Accommodation - other please state?
Planned Activities:
Trekking/Altitude
Cycling
Rafting/Boating
Scuba Diving
Other (please state)
Planned Activities? Other please state
Name of Person completing
Person completing is?
Self
Parent
Caregiver
Guardian
Today's date
SEND
