Pre Travel Checklist

Pre Travel Checklist
Multiple vaccines may be recommended dependent on your destination(s). Vaccines are not available without first having a travel consultation. Travel Consult Fees and Vaccination Fees are payable on the day. Yellow fever consultations usually require 30 minutes per person. Please note, you may need a separate (nursing) appointment for the vaccine.
Patient Details
Full Name*
Date of birth*

DayMonthYear
NHI Number (if known)
Address*

Street Address

Suburb

City

Post Code
Contact Phone Number*
Email Address*
example@example.com
Which ethnic group(s) do you belong to?*

New Zealand MāoriNew Zealand EuropeanSamoanCook Island MāoriTonganNiueanChineseIndianOther
Usual GP Name and Address?*
If you would like a combined travel appointment with your travelling companions, please write their name(s) below.
Emergency Contact or Next of Kin
Name*
Phone Number*
Relationship to you*
Trip Details
Departure date for this trip*

MonthDayYear
Date
Who are you travelling with?*

AloneWith FamilyWith FriendsIn a tour group
Please list the countries you are visiting in order of stay. Please include country, if the location is rural or urban, region, length of stay and type of accommodation.*
Purpose of trip - select all that apply.*

HolidayBusinessVisiting friends or relativesTo obtain medical or dental treatmentEducationVolunteer or Missionary workAdoptionOther
Activities - select all that apply.*

DivingTrekkingHigh AltitudeSafariHiring Car/MotorbikeOrganised sporting activityPotential exposure to body fluids (e.g. tattooing)Potential new sexual partnersNone of the above
What mode(s) of transport will you be using while overseas?*
Past Travel Experience*
Do you have travel insurance for this trip?*

YesNo
Medical History*

Heart DiseaseAsthma/Lung DiseaseStrokeBlood ClotDiabetesMental Health ConditionSkin ConditionArthritisImmune DisorderEpilepsyCancerRecent SurgeryOtherNone of the above
If you selected Other, please indicate below.
Please indicate any regular medications, including inhalers, injections or contraception. *
Please indicate any Allergies.*
Are you pregnant?*

YesNo
Are you breastfeeding?*

YesNo
Do you or your partner intend to become pregnant in the next 12 months?*

YesNo
Are you up to date with your childhood vaccinations?*

YesNoUnsure
Does having an injection make you feel faint or pass out?*

YesNo
Have you taken medication or prevent Malaria in the past?*

YesNo
Do you believe you need Yellow Fever vaccination?*

YesNo

Have you had any of the following vaccinations, and if so when?*

	Vaccination	Date
Hepatitis A
Hepatitis B
MMR
Meningococcal
Tetanus
Typhoid
Whooping Cough
Polio
Cholera
Rabies
Yellow Fever
Tuberculosis (BCG)
Japanese Encephalitis
None of the above

If I receive a vaccine at Riccarton Clinic, I would like my regular GP practice advised.*

YesNo
I understand that I need to bring my vaccine record with me to my travel appointment*

Yes
Should be Empty:

Pre Travel Checklist

Patient Details

Emergency Contact or Next of Kin

Trip Details