Please complete the following if there have been any changes in your details since your last visit
Have your private health insurance details changed
If yes, how:
Do you want a copy of your vaccination records sent to your doctor?
Your doctor's name and address:
Please list any new medications you are taking now (e.g contraceptive pills, antibiotics):
Have you developed any allergies since your last visit
If yes, please state:
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
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: