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Pre-Travel Questionnaire

Note : Please bring any vaccination records (childhood/travel), travel itinerary and confirmation of this form submission when you arrive at the clinic. Please fill this form for each member of the family separately.

Pre -Travel Questionnaire

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Pre -Travel Questionnaire

Name *

First

Last

Phone

Email *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

What is your Gender? *

Male
Female

What is your date of birth? *

What is your weight?

Alberta Healthcare Number

Family Doctor's Name *

First

Last

Your Family Doctor's Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Family Doctor's Phone Number

Family Doctor's Fax Number

Have you been immunized as a child?

Yes
No

When are you planning to travel?

Where are you planning to travel?

First

Middle

Last

What is the duration of your total trip?

Please mention the duration of stay. Eg. 1 Month, 2 Weeks

What is your purpose of travel?

Business or Work
Vacation
Volunteer / Mission
Backpacking
Visiting Family / Friends
Others

What are the activities planned during travel?

Rural/remote
Urban/city
Diving
High Altitude
Surfing
Camping
Climbing
Swimming
Tour
Snowboarding
Other

Have you had any side effects/reactions from previous medications?

Yes
No

Your Immune System:

Steroids by mouth within last 3 Months
Immune suppressive medications or treatments within last 3 months. ( e.g: radiation, cancer chemotherapy drugs, methotrexate, azathioprine, adalimumab, anakinra, etanercept, infliximab, leflunomide, rituximab)
Spleen Removed
Thymus disease or thymectomy
HIV / AIDS
Organ, bone marrow, stem cell transplant
Other

Cardiovascular

Arrhythmia (rhythm disturbance considered significantly abnormal including atrial fibrillation, heart block)
Implanted pacemaker or automatic defibrillator
Heart Attack
High Cholesterol
High Blood Pressure
Stroke
Other

GI

Chrohn's disease or ulcerative colitis
IBS
GERD
Chronic hepatitis
Cirrhosis or liver failure
Other

Neurologic/psychiatric

Seizures or epilepsy
Anxiety/depression
History of Guillain-Barre
Chronic hepatitis
Other

Cancers or blood disorder

Coagulation disorder
History of cancer or blood disorder
Other

Kidneys

Dialysis
Kindney insufficiency
Other

Lungs

Asthma
Emphysema/COPD
Other

Endocrine

Diabetes
Thyroid disease
Other

Musculoskeletal

RA
Psoriatic arthritis
Other

Skin

Psoriasis
Other

Please check if you have any allergies to the following

Antibiotics (e.g: penicillin, sulfa)
Other medications
Egg
Latex
Gelatin
Yeats
Bees / Wasps
Seasonal
None
Other

Are you currently taking any medication?

Yes
No

Current Medications

First

Last

2

First

Last

2 (copy)

First

Last

Single Line Text

Non-Prescription Products

First

Last

2 (copy)

First

Last

2 (copy) (copy)

First

Last

Single Line Text (copy)

Have you received Hepatitis A immunizations in the past?

Yes
No

If Yes, please provide details such as approximately when and how many doses in the next.

Have you received Hepatitis B immunizations in the past?

Yes
No

If Yes, please provide details such as approximately when and how many doses in the next.

Have you received Hepatitis A&B immunizations in the past?

Yes
No

If Yes, please provide details such as approximately when and how many doses in the next.

Have you received any Meningococcal vaccines in the past?

Yes
No

If Yes, please provide details such as approximately when and how many doses in the next.

Have you received any immunization for Measles/Mumps/Rubella in the past?

Yes
No

If Yes, please provide details such as approximately when and how many doses in the next.

Have you received any vaccination for Polio in the past?

Yes
No

If Yes, please provide details such as approximately when and how many doses in the next.

Have you received any vaccination for Tetanus in the past?

Yes
No