Please Note: This form should only be completed after a consultation appointment has been booked. If you are scheduled for a travel consult, you can save time by completing the travel medicine questionnaire before your appointment:

Section 1 - About You
Name
Date of Birth
(DD/MM/YYYY)
Health Card Number
Address
Postal Code
Home Phone Number
Work Telephone Number
Name of Family Doctor


Section 2 - Countries to be Visited
Indicate which Countries are you visiting, in the order you visit them
Country #1 - Name (e.g. Rwanda)
Country #1 - Urban or Rural visit





Country #1 - Length of Stay
Country #2 - Name
Country #2 - Urban or Rural Visit





Country #2 - Length of Stay
Country #3 - Name
Country #3 - Urban or Rural Visit





Country #3 - Length of Stay
Country #4 - Name
Country #4 - Urban or Rural visit





Country #4 - Length of Stay
Additional Countries


Section 3 - About Your Trip
Date of Departure
(DD/MM/YYYY)
Is this a:
  • Business trip: very comfortable; excellent hygiene
  • Tourist Trip: well organized, very comfortable, confined to classic tourist sites
  • Adventure Trip: organized across isolated areas (low budget travelling), long trips covering several countries, all trips more than 3 weeks
  • Extended Stay: work contracts of one - two years
  • Mission
  • Sporting Event
  • Other
Purpose of your trip
(see above)














Other Purpose (if any)
Are You Travelling with:







Accomodations











Other Accomodation (if any)
Any Special Planned Activities









Other Special Activities (if any)


Section 4 - Your Travel, Immunization, and Medical History
Have you ever visited other countries?



Countries visited previously
Your Immunization history:
List whether you have had the following vaccinations, and the date (if known):
Prior Vaccinations received:























Other Vaccinations Received
Date of Tetanus/Diptheria Vaccination
Date of Typhoid Vaccination
Date of Poliio Vaccination
Date of Influenza Vaccination
Date of Yellow Fever Vaccination
Date of Pneumococcal Vaccination
Date of Meningococcal Vaccination
Date of First MMR (#1)
Date of Second MMR (#2)
Date of First Hep. B (#1)
Date of Second Hep. B (#2)
Date of Third Hep. B (#3)
Date of First Hep. A (#1)
Date of Second Hep. A (#2)
Date of First Twinrix (#1)
Date of Second Twinrix (#2)
Date of Other Vaccinations Received
Have you ever had any adverse reactions to any of the Immunizations? If so, then provide details below:
Any Adverse Reactions?
Have you ever had Chicken Pox?



Do you have Allergies to:

















Other Allergies (if any)
Do you have a Chronic/Serious illness?



Details of Chronic/Serious Illness
Are you taking any medications? If so, please list them below. Remember to bring your medications with you to your appointment at the Travel Clinic at Mediplex.
List Your Current Medications
Do you have a History of:







History Details


Please click the "Submit this Form" button below to send your Pre-Visit Questionnaire to The Travel Clinic at the Mediplex. Your Privacy is important to us. Our Privacy Policy may be viewed at http://www.mediplex.ca.