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THE MORE INFORMATION YOU PROVIDE
THE MORE SPECIFIC THE TRAVEL HEALTH ADVICE WILL BE.
(FIELDS MARKED WITH * ARE MANDATORY)
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PERSONAL INFORMATION |
TITLE
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E MAIL *
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Please use the same email for payment transaction as well ! |
COUNTRY OF RESIDENCE
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DATE OF BIRTH
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GENDER |
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PLEASE PROVIDE MORE INFO REGARDING YOUR PREGNANCY IF APPLICABLE |
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PREGNANT |
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BREASTFEEDING |
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PLEASE PROVIDE MORE INFO REGARDING YOUR PREGNANCY
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ALLERGIES |
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PLEASE PROVIDE MORE INFO REGARDING YOUR ALLERGIES |
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DO YOU EXERCISE REGULARLY ?
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WEIGHT IF UNDER 16 YRS |
( KGS ) |
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PLEASE PROVIDE MORE INFO ON ANY MEDICATION YOU TAKE REGULARLY
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MEDICAL HISTORY
This area is not mandatory but helpful if you have the information
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PLEASE PROVIDE ANY INFORMATION ON ANY RECENT SURGERIES OR CHRONIC MEDICAL CONDITIONS EG. DIABETES, ASTHMA, CARDIAC CONDITIONS ETC.
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VACCINATION HISTORY
Please be as accurate as possible.If unsure, leave blank or consult your vaccination book. |
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| POLIO |
LAST DOSE |
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TETANUS |
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| TYPHOID |
LAST DOSE |
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HEPATITIS A |
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HEPATITIS B |
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COMBINED HEPATITIS A & B |
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| YELLOW FEVER
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LAST DOSE |
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MENINGOCOCCAL ACWY |
LAST DOSE |
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MENINGOCOCCAL A&C |
LAST DOSE |
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BCG / TUBERCULOSIS |
LAST DOSE |
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MEASLES / MUMPS & RUBELLA |
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DOSE 2 |
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CHICKEN POX ILLNESS
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CHICKEN POX VACCINE
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ANY OTHER VACCINES e.g. CHOLERA, JAPANESE ENCEPHALITIS ?
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ANY OTHER FURTHER INFO / PREVIOUS TRAVEL EXPERIENCE ?
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TRAVEL INFORMATION
(Please give as much details as possible- not just countries you are travelling to but cities and areas within that country) |
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DESTINATIONS & DATES YOU ARE TRAVELLING*
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| Will you be travelling to any other countries within the previous 6 days from the date the above travel will commence ? |
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| If YES please elaborate... |
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TYPE OF TRAVEL |
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BUSINESS
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PACKAGE |
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BACKPACKING |
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VISITING FAMILY
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| OTHER PLEASE SPECIFY |
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WHAT
ACTIVITIES ARE YOU PLANNING TO DO?
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Thank You For Completing the Pre Travel Questionnaire! |
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DISCLAIMER
Every effect has been made to ensure all information emailed to you is correct and up to date. Travel Health Nurse relies on numerous reliable sources including cdc (Centers for Disease Control and Prevention), WHO (World Health Organisation) and ProMED (the global electronic reporting system for outbreaks of emerging infectious diseases). However travellers with medical conditions should be assessed by their doctor before any travel.
Travel Health Nurse will not be held liable for any action, injury or illness resulting directly or indirectly from suggestions made, or omissions of information.
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