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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
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