Travel Medicine Booking Form

Full Name

Date of Birth

Phone Number

Email

Please list which countries you are visiting, for how long and what regions within each country?

Date of Departure from Wanaka

Expected duration of travel

Are you visiting friends or relatives?

Are you planning to do any aid work?

Does your trip involve travel to altitude over 2000 meters or you plan to Scuba Dive?

If yes, have you been to altitude before and experienced any problems?

Will you be participating in any risk activities (e.g.: diving, mountaineering, climbing, kite surfing etc.)?

Are you visiting rural areas, jungle or going on a safari?

List any previous or current medical conditions

Have you had deep vein thrombosis (DVT) in the past?

Have you had any surgery or major illness, including hospital admissions, in the last 6 months?

If yes, what?

Current medications (including contraceptive pill)

Do you have any allergies (including medications and foods)?

If yes, what?

Are you pregnant or planning pregnancy?

Are you breastfeeding?

Have you been treated with steroids in the past 2 years?

Do you suffer from any condition causing immunodeficiency?

Have you ever had any thymic disorders or myasthenia gravis?

Have you ever smoked?

If you are a current smoker, would you like advice on quitting?

If yes, what?

Polio

Tetanus / Diphtheria

TB (BCG)

Hepatitis A 1st Immunisation

Hepatitis A 2nd Immunisation

Hepatitis B 1st Immunisation

Hepatitis B 2nd Immunisation

Hepatitis B 3rd Immunisation

Typhoid

Meningitis ACWY

Rabies 1st Immunisation

Rabies 2nd Immunisation

Rabies 3rd Immunisation

Japanese Encephalitis 1st Immunisation

Japanese Encephalitis 2nd immunisation

Yellow Fever

Influenza

Others? Please list

Did you have all your childhood immunisations?

Which country did you have your childhood immunisations in?

Have you had any reaction to previous immunisations?

If yes, please describe what reaction you had.

Travel Details

Medical History

If you have had travel immunisation before please complete the date given beside the immunisation you have had?

Immunisation History

Monday - Friday

Weekends and Public Holidays

After Hours

Email

Aspiring Medical Centre

Book an appointment

Repeat prescriptions

Request a GP call-back