Travel Clinic Pre-Consultation Form
Personal Details
Salutation
*
Please Select
Mr
Mrs
Ms
Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Gender
*
Male
Female
Address
*
Mobile Phone Number
*
Email
*
GP Details
*
Date of departure
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Return date
*
/
Day
/
Month
Year
2 digit day, 2 digit month, 4 digit year
Overall length of stay
Itinerary and purpose of visit
Rows
Country to be visited
Length of stay
1
2
3
4
5
Travel propose
*
Adventure
Cruise
Diving
Healthcare worker
Long-term (backpacker / expatriate / volunteer / work)
Medical access?
Medical tourism
Natural disasters
Remote
Pilgrimage
Visiting friends & relatives (VFRs)
Trek
Other
Personal medical history
Tick which of the following applies to you
Rows
Yes
No
Details (reconfirm at each
appointment)
Are you feeling well today? Do you have a fever?
Do you have any recent or past medical history of note?
Have you had any immunizations in the past 3 weeks?
Do you have any allergies to eggs, latex, nuts or antibiotics?
Do you take any current or repeat medicines?
Have you had a serious reaction to a vaccine before?
Does having an injection make you feel faint?
Do you or any of your family suffer from epilepsy?
Recently undergone radiotherapy, chemotherapy, steroids?
Do you have a medical history of the following: anxiety, depression,
heart, lung, spleen, joint, liver, kidney, immunity, blood conditions,
disorders, diabetes, HIV/AIDS
Please write below any further information which may be relevant
Vaccination History
Have you ever had any of the following vaccinations / malaria tablets and if so when?
Rows
Enter Here
Diphtheria
Influenza
Meningitis
Tetanus
Yellow Fever
Hepatitis A
Jap B Enceph
Polio
Tick Borne
Other
Hepatitis B
Malaria Tablets
Rabies
Typhoid
Personal medical history
Tick which of the following applies to you
Rows
Yes
No
Details (reconfirm at each
appointment)
Allergies (including food, latex, medication etc.)
Anaemia
Bleeding/ clotting disorders (including deep vein thrombosis)
Diabetes
Disability
Epilepsy/seizures
Gastrointestinal (stomach) complaints
HIV/AIDS
Immune system condition
Kidney problems
Liver problems
Mental health issues (including anxiety, depression)
Neurological (nervous system) illness
Respiratory (lung) disease
Rheumatology (joint) conditions
Spleen problems
Any other conditions
Women only
Tick which of the following applies to you
Rows
Yes
No
Details (reconfirm at each
appointment)
Are you pregnant? Or planning a pregnancy?
Are you breast feeding?
Submit
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