Fairview Pharmacy

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Travel Clinic Consultation Form

Travel Clinic Consultation Form

Completing this form should take no longer than 5-10 minutes and will assist our clinician in evaluating your suitability for the travel clinic. Rest assured that all information provided will be handled with the utmost confidentiality and will only be viewed by our healthcare professionals. During your consultation, you'll have the opportunity to discuss any concerns or questions you may have. Thank you for choosing our travel clinic. We look forward to assisting you!
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Name
Date of Birth
Address
Travel Purpose
Are you feeling unwell today? Do you have a fever?
Do you have any medical conditions? (Tick which of the following applies to you)
Have you had any immunisations in the past 3 weeks?
Do you have any allergies to eggs, latex, nuts or antibiotics?
Do you take any current or repeat medicines?
Have you had a serious reaction to a vaccine before?
Does having an injection make you feel faint?
Do you or any of your family suffer from epilepsy?
Have you recently undergone radiotherapy, chemotherapy, steroids?
Do you have a medical history of the following: anxiety, depression, heart, lung, spleen, joint, liver, kidney, immunity, blood conditions, disorders, diabetes, HIV/AIDS
Are you pregnant? Or planning a pregnancy?
Are you breast feeding?