Your Medical Home

 

Travel Doctor - Returning Client's Form

Your Details

 

Please complete the following if there have been any changes in your details since your last visit

 

Contact Address:

 

Have your private health insurance details changed

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


Your Health

Have you developed any allergies since your last visit



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


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