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