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:

1
2
3
4
5
6
7
8