Travel Medicine Clinic Pre-Visit Questionnaire 


SECTION ONE - ABOUT YOU
Name *
Name
Date of Birth *
Date of Birth
Address *
Address
Home Phone Number *
Home Phone Number
Work Phone Numer *
Work Phone Numer
SECTION TWO - COUNTRIES TO BE VISITED
Indicate which countries are you visiting, in the order you visit them.
e.g. Rwanda
Country #1 - Urban or Rural visit *
e.g. 21 days
Country #2 - Urban or Rural visit
Country #3 - Urban or Rural visit
SECTION THREE - TRIP DETAILS
What accommodations will you be staying
Any special planned activities
SECTION FOUR - PREVIOUS TRAVEL
Previous International Travel
SECTION FIVE - IMMUNIZATION HISTORY
MMR #1 Date
MMR #1 Date
MMR #2 Date
MMR #2 Date
MMR#3 Date
MMR#3 Date
Hepatitis B #1 Date
Hepatitis B #1 Date
Hepatitis B #2 Date
Hepatitis B #2 Date
Hepatitis B #3 Date
Hepatitis B #3 Date
Hepatitis A #1 Date
Hepatitis A #1 Date
Hepatitis A #2 Date
Hepatitis A #2 Date
Hepatitis A #3 Date
Hepatitis A #3 Date
Twinrix #1 Date
Twinrix #1 Date
Twinrix #2 Date
Twinrix #2 Date
Twinrix #3 Date
Twinrix #3 Date
Did you have any adverse reactions to any of the immunizations
Have you had Chicken Pox
Allergies
Do you have a chronic/serious illness
Do you have a history of any of the following