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07 5470 2211
Our Location:
22 Doonella St, Tewantin, 4565 Q

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HOME
ABOUT OUR PRACTICE
SERVICES
- TRAVEL CLINIC
- SKIN CLINIC
DOCTORS & STAFF
PATIENT INFO
- FORM DOWNLOADS
- FEES & BILLING
FAQ
BOOK ONLINE
CONTACT

Travel Clinic - Patient Questionnaire

Our online form is quite lengthy, please include as much information as possible to help us assess your needs.

This form should be completed at least 2 days prior to appointment date.

If you have any questions or need help with this questionnaire, please call our friendly staff on 5470 2211.

Page 1 of 8

Patient Details

Patient Name

First

Last

D.O.B*

Email address*

Your regular GP name

Contact phone*

Emergency contact phone

Date of departure*

Health Background

Please fill in the following fields, all are required.

Current Medical Conditions:*

Past Medical Conditions or Operations: *

Allergies (medications, vaccines, egg, latex, other): *

Current Medications (prescribed and over-the-counter):*

Immunisation History

Please input any dates if known

Diphtheria

Tetanus

Pertussis (Whooping Cough)

Measles

Pneumovax (Pneumonia)

Rabies

Polio

Influenza

Meningitis (B, ACWY)

Mumps

Japanese Encephalitis

Yellow Fever

Hepatitis A

Zoster (Shingles)

HPV

Rubella (German Measles)

Typhoid

Tick Encephalitis

Hepatitis B

TB (BCG)

Mantoux

Varicella (Chickenpox)

Cholera + ETEC

Other

Specific Conditions

Please tick any conditions that are applicable

Pregnancy

Yes

Present or past history of psychiatric illness (including depression, anxiety, bipolar etc)

Yes

Recent lung/chest/breathing illness

Yes

Breastfeeding

Yes

Seizures, fits, head injury

Yes

Stroke or TIA

Yes

Disability

Yes

Recent surgery (within last 3 months)

Yes

DVT (deep vein thrombosis), PTE (Pulmonary Thrombo-Embolism) or clotting disorder

Yes

Immune deficiency (eg HIV, steroid therapy, immunosuppressant therapy for rheumatoid arthritis etc)

Yes

Recent heart condition/illness

Yes

Recent heart condition/illness

Yes

Previous Travel Information

Experience with MALARIA TABLETS previously? If yes, name of drug:

Any side-effects?

Previous experience with ALTITUDE, and any problems?

Any previous travel-related illnesses?

Trip Details Information

Countries and regions on itinerary, in chronological order

Rural or Urban travel?

Duration of trip/time to be spent in each location?

Season of travel?

Purpose of Travel

Please tick relevant option/s

Tourism

Business

Visiting friends or relatives

Research or study

Adventure

School group

Seeking health care/surgery (medical tourism)

Other

Travel Style

Independent travel

Yes

No

Modes of transportation:

Organised Tour

Yes

No

Accommodations (eg; luxury hotel, guest house, hostel, tent, host home)

Special Activities + Additional Info

Special Activities

High altitude trekking or climbing

Diving

Cruise ship

Cycling

Extreme sports/adventure

Camping

Rafting

Disaster relief/Aid work

Other

Additional Information

Any additional information? Any further issues you would like to discuss?

This field should be left blank

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