Travel Clinic Questionnaire

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– Step 1 of 4

Name *

First

Last

Guardian/Parent name (if applicable)

First

Last

We need your travel itinerary

We need to have your travel details on file in order to be able to understand which vaccinations are available to you as part of the travel consultation service.

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Departure date *

Arrival date *

Email adress *

We need your email address to send you summary of your questionnaire

Select a country from the list below to identify the disease risk in the area *

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Cholera

Hepatitis B

Rabies

Typhoid fever

Malaria

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Cholera

Hepatitis B

Rabies

Typhoid fever

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Cholera

Hepatitis B

Typhoid fever

Malaria

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Typhoid fever

Malaria

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Rabies

Tick-borne encephalitis

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Rabies

Typhoid fever

Tick-borne encephalitis

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Tick-borne encephalitis

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Rabies

Tick-borne encephalitis

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Rabies

Typhoid fever

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Typhoid fever

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Rabies

Yellow fever

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Japanese encephalitis

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Rabies

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Cholera

Hepatitis B

Rabies

Typhoid fever

Yellow fever

Malaria

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Rabies

Typhoid fever

Japanese encephalitis

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Rabies

Typhoid fever

Japanese encephalitis

Malaria

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Japanese encephalitis

Tick-borne encephalitis

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Cholera

Hepatitis B

Rabies

Typhoid fever

Japanese encephalitis

Malaria

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Cholera

Hepatitis B

Rabies

Typhoid fever

Japanese encephalitis

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Cholera

Hepatitis B

Rabies

Typhoid fever

Japanese encephalitis

Malaria

Tick-borne encephalitis

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Cholera

Hepatitis B

Rabies

Japanese encephalitis

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Cholera

Hepatitis B

Rabies

Japanese encephalitis

Malaria

Tick-borne encephalitis

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Rabies

Typhoid fever

Yellow fever

Malaria

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Rabies

Typhoid fever

Malaria

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Typhoid fever

Malaria

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Rabies

Malaria

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Rabies

Cholera

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Cholera

Hepatitis B

Meningitis ACWY

Rabies

Typhoid fever

Yellow fever

Malaria

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Rabies

Typhoid fever

Yellow fever

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Cholera

Hepatitis B

Meningitis ACWY

Rabies

Typhoid fever

Yellow fever

Disease risk

Hepatitis A

DTP (diphtheria tetanus poliomyelitis)

Hepatitis B

Meningitis ACWY

Rabies

Malaria

From the disease risk listed above, please identify the diseases you require protection from: *

Hepatitis A
DTP (diphtheria tetanus poliomyelitis)
Cholera
Hepatitis B
Japanese encephalitis
Meningitis ACWY
MMR (measles, mumps and rubella)
Rabies
Tick-borne encephalitis
Typhoid fever
Malaria
Yellow fever

Define activities

Please provide as much information as you can to describe the trip you are undertaking.

Please select from the listed options to best describe your accommodation, reason for travel and the possible activities you may take part in for ALL the countries during your trip.

You may tick more than one box per section. This must include at least one pre-defined option – you cannot just select ‘Other’.

What sorts of places are you staying at? *

Staying in a hotel
Staying with friends or relatives
Local or rented accommodation
Staying at a backpacker hostel or bed and breakfast accommodation
Camping
Staying at a refugee camp or volunteer centre
Staying on a cruise ship
Other

Please provide details

Reason for travel and activities? *

Business travel
Hajj or other pilgrimage
Holiday
Visiting friends or relatives
Student gap year / backpacker
Adventure
Volunteer work / missionary work
Adventure sports or extreme activities (for example remote trekking, motorcycling or cycling)
Possibility to be sexually promiscuous
To receive medical treatment
Diving
Visiting high altitude areas
Expatriate
Refugee / natural disaster
Other Activities

Please provide details

Medical screening

Please ensure the answers on the questionnaire are correct, paying particular attention to names of listed conditions and medicines.

Are you currently taking any prescription medications?

It is important to check medication names and dosage instructions to ensure accurate information is entered on the system.

Please list dose and frequency (Failing to provide accurate information may delay the process)

Have you had a high fever or temperature in the last 24 hours? *

For how long have you had this fever and what is the cause?

Are you taking any regular medication which thins your blood or prevents it from clotting, excluding aspirin 75mg? *

Please provide details

Is there any possibility that you could be pregnant? *

Do you have any ongoing medical problems? *

Provide details of any ongoing medical problems or conditions, such as diabetes, asthma, coronary heart disease, etc…

Vaccination history

Please record any previous travel vaccinations

If you have received any doses of vaccines in the past, please record vaccine and year

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Vaccine

Year

Provide details of any ongoing medical problems.

Indicate if you have any of the following. Tick all that apply *

Diabetes
High blood pressure
Asthma
Cerebral disorder (e.g. epilepsy or stroke)
Kidney problems
Liver problems
Sickle cell
Porphyria
Myasthenia gravis
Other ongoing medical condition(s)
No ongoing medical conditions

Are you receiving dialysis? *

Please provide details

Do you have a bleeding disorder, including taking any medication that thins your blood (anticoagulants)? *

Please provide details

Are you immunosuppressed due to disease or treatment? *

Please give more information on what your low immunity issues are. Provide clear details of your condition, including dates, and your current situation.

Indicate if you have any of the following immunity related issues below. *

Are on dialysis
Have had a solid organ or bone marrow or stem cell transplant
Have received chemotherapy or radiotherapy within the last 6 months
Have taken immunosuppressants in the last 6 months
Are immunocompromised
Have HIV
Have had your spleen removed
Are currently taking or have taken steroids in the last month
None of the above

Have you had any operations in the last six months? *

Please provide details

Do you have or have you ever had any allergies? *

Your Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Your Phone Number *

Date of Birth

Please choose the type of clinic you are booking

A walk in clinic
A video consultation (For supply of tablets or capsules ONLY. You will need to visit the clinic for injections)

A video link will be sent prior to appointment if you choose a video consultation.

Please provide more details. For example, do you need travel vaccinations for a family member. Please give details.

GPs Name & Address

Patient Consent (copy)

I am happy to share details of this consultation with my GP.
I DO NOT want to share details of this consultation with my GP.

Click to view pharmadoctor terms & conditions

Patient Consent 2

I am happy to access treatment from Tabi Health
I have read the Pharmadoctor terms and conditions
I have answered the questions above honestly

Patient ID

I will have available proof of ID (such as passport, drivers license or photocard) during consultation.

We recommend at least 2 to 3 days notice prior to your appointment date, to give us time to order your medication.

Travel Clinic Questionnaire

We need your travel itinerary

Define activities

Medical screening

Vaccination history

Start Assessment

Complete Patient Details