Petone Medical Centretravel Advice

Petone Medical CentreTravel Advice

Thank you for your enquiry regarding overseas travel advice. We look forward to assisting you with your health requirements to help you to stay well during your travel and upon your return. Please fill out the attached form including all details requested, especially past vaccination history. Without this information we will not be able to provide you with accurate advice for your trip, and you may be advised to have vaccinations, which may not be necessary.

Please return the completed questionnaire to the Practice Nurse. Your questionnaire will be processed as soon as possible and the Practice Nurse will contact you to arrange an appropriate appointment. In some situations it may be necessary for you to see the nurse as well as the doctor. The nurse will advise you of this at the time.

Please do not book an appointment yourself. Wait to be contacted.

It is important that we receive your completed questionnaire at least 7-8 weeks prior to travel as full vaccination sometimes requires a course of vaccinations, and malaria protection (if required) may need to be commenced 2 weeks prior to travel.

We request a $50 deposit on the return of these forms. This will be deducted from the cost of your consultation.

Charges for this service will range between $12-34. Vaccinations (which vary in cost) will be charged separately.

You may like to peruse the attached booklet regarding travel health as it may assist you with any decisions you may make regarding vaccinations.

Petone Medical Centre Pre-Travel Medical Questionnaire

Name: ______

Address: ______

______

Phone: (Home)______(Work) ______(Mobile) ______

Date of Birth: _____/_____/______Country of Birth: ______

Travel Information:Departure Date: ______

Purpose of travel: (please circle)

Holiday / Mission or Voluntary Work / Adventure Holiday (Backpacking, safari etc) / Business

Other (Please specify) ______

Are you travelling: (please circle) Alone / with family / friends

Type of Travel: (please circle)

Fixed Itinerary / Group Tour / Independent / Cruise Ship / Backpacking

Proposed Activities while travelling: (please circle)

Diving / Trekking / Safari / Climbing (above 3000mtrs) / Rafting / Cycling

Other (Please specify) ______

Travel Itinerary: Please list destinations in order of travel

Country / City / Town / Dates

Attach copy of Itinerary if possible.

Will you be visiting any rural areas? Yes / No

Past Travel History: Please list countries visited and approximate dates

______

______

______

Medical History: Please list any current medical conditions e.g. Diabetes; asthma; heart disease; high blood pressure; mental health issues etc

______

______

______

______

OR: I have no current medical conditions

PTO --

Do you smoke? Yes / No If yes, number of cigarettes smoked per day ______

Do you drink alcohol? Yes / No If yes, how many drinks per week ______

To your knowledge, are your usual childhood immunisations up to date? Yes / No

Immunisation History: Please list below your past vaccinations.

Vaccination

/

Dates Received

/

Vaccination

/

Dates Received

Tetanus / Diphtheria / Hepatitis A
Measles / Mumps / Rubella / Hepatitis B
Polio / Typhoid
Influenza / Rabies
Chickenpox (Varicella) / Yellow Fever
Whooping Cough (Pertussis) / Japanese Encephalitis
Pneumococcal disease / Meningococcal Meningitis
Haemophilus Influenza B / Cholera

Please list all medications you currently take:

Medication

/ Dose (Strength – mg) / Frequency (e.g once daily)

Do you have any drug or other allergies? Yes / No

Please specify ______

Weight: ______kg

Please tick if you have a past or present history of:

Stomach or bowel problems e.g. indigestion, celiac disease, irritable bowel / Immune disorder e.g leukaemia, HIV, cancer treatments, immune-suppression medication
Skin conditions e.g skin cancer, psoriasis, eczema / Mental health disorder e.g depression, anxiety
Seizures, fits or faints / Nightmares – ongoing
Thymus disorder / Heart problems
Removal of spleen / Kidney disease or renal stones

Women Only

Are you currently pregnant Yes / NoDate of last menstrual period ______

Are you considering a pregnancy within 3 months of your travel? Yes / No

Are you currently breastfeeding? Yes / No