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.

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Patient Details

Health Background

Please fill in the following fields, all are required.

Immunisation History

Please input any dates if known

Specific Conditions

Please tick any conditions that are applicable

Previous Travel Information

Trip Details Information

Purpose of Travel

Please tick relevant option/s

Travel Style

Special Activities + Additional Info

Special Activities

Additional Information