Date of Birth:
Place of Birth:
Do you have Health Insurance?
Your doctor's name and address:
Have you travelled to developing countries before?
If yes, please list countries:
Did you have any health issues while away?
Do you have
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
Please list any medications you are taking now (e.g contraceptive pills, antibiotics):
Please list any medications you occasionally take (e.g. migraine tablets, ventolin, vitamins):
Do you have any allergies particularly to medications/egg/latex/band aids:
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
Please outline any particular health concerns regarding this trip:
List dates for:
Returning to 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: