Pre-Travel Questionnaire

  • Thank you for booking your travel health consultation!

    Before your appointment, please complete the Travel Health Form below; this will save time later and allow more time to discuss your trip!

    Get Started - complete your Travel Health Form now.

  • 1/3 General Information
    Please provide the following details about your trip:

  • Format: (000) 000-0000.
  • Departure Date:
     - -
  • Return Date:
     - -

  • Return date must be after Departure date.

  • 2/3 Medical History

  • If you are suffering from a fever or other infection you should inform your health professional on the day you visit for vaccinations.

  • I am allergic severely to the following things: (Select any that apply)
  • I have the following conditions: (Select any that apply)

  • 3/3 Vaccination History

  • I have had these vaccinations in the past four weeks: (Select any that apply)

  • Malaria Medication History:

  • I have previously taken the following malaria medication: (Select any that apply)
  • When I took the malaria medication:
  • Should be Empty: