Territory Medical Group - Travel Consult Questionnaire

Please remember to bring a list of your previous travel vaccinations as well as your yellow book to your consult.

Please enter your unique patient identifier *

Please enter the name of the Doctor you are seeing *

Please enter the date of your travel consult * +

Your Health

Have you traveled to less developed countries before? *

Please specify any health problems you had while away

Have you ever had any serious medical problems? * 🛈

If yes, please specify

Have you been admitted to hospital in the past 6 weeks? *

Have you ever had the disease Hepatitis? * 🛈

Are you taking any medications now? * 🛈

If yes, please specify

Do you have any known allergies? *

If yes, please specify (Please discuss with Doctor during consult)

Have you ever had any adverse reactions to immunisations? *

If yes, please specify (Please discuss this with your Doctor)

Are you breastfeeding, currently pregnant or planning to become so within 3 months of your return? *

Did you miss any of your childhood vaccines? *

If yes, please specify

Do you have any particular health concerns regarding this trip? Please outline: *

Please list in order the countries you intend to visit, and how long in weeks you plan to spend in each *

+-

What is the main purpose of your trip? *

If other, please specify *

Do you have travel insurance? *

Type of accommodation? *

If other, please specify *

Will you be undertaking any adventure activities? *

If other, please specify *

Date leaving Australia *

Return date to Australia *

Are you interested in purchasing a travel kit from Territory Medical Group? *