Your Medical Home


Travel Doctor - New Client's Form

Your Details

Do you have Health Insurance?

Do you want a copy of your vaccination records sent to your doctor?

Your Health


Have you travelled to developing countries before?

Did you have any health issues while away?

Do you have a family history of blood clotting disorder, clots in he veins or lungs, (pulmonary embolus)?

Have you ever had the disease Hepatitis A (Yellow Jaundice)

Have you ever felt faint or fainted after an injection or giving blood
Women only - Could you be pregnant now OR do you plan to become pregnant within 3 months of your return

Are you in contact with anyone with a weakened immune system? e.g. people with AIDS, cancer sufferers on chemotherapy, people taking steroid drugs

Did you miss any of the usual childhood vaccinations

Your Trip


List dates for:

Leaving Australia

What is the main purpose of your trip? :

Who will you be travelling with

Please list in order the countries you intend visiting and approximately how long (in days) you plan to spend in each: