Chromis Travel Medicine >

Health questionnaire for
international travel

Two options to choose from

Fill out our online form below or download it, fill it in and send to us.

Your personal details

The detailed information we require is necessary to enable us to give you individual advice tailored to your specific travel
arrangements and health. Confidentiality is assured.

If you are travelling as a couple or a family, please fill in the form for each member who will be coming for an appointment with CHROMIS.

First name
Surname
Age
Date of birth
Gender	Male Female
Address
Suburb
State	Postcode
Phone (H)
Phone (W)
Mobile
Email
Country of birth
Nationality
Occupation
GP

Are your visits being paid by your employer?


Company name:
Your health fund:

How did you hear about Chromis Travel Medicine?


Name:
Name:
Please state:

Dates of your trip

Depart
Return

Countries you will visit

Number

Please fill in the details below for each country you are visiting.

Country
Cities / areas
Length of stay

Country
Cities / areas
Length of stay

Country
Cities / areas
Length of stay

Country
Cities / areas
Length of stay

Country
Cities / areas
Length of stay

Country
Cities / areas
Length of stay

Country
Cities / areas
Length of stay

Country
Cities / areas
Length of stay

Country
Cities / areas
Length of stay

Please describe the nature of your trip


Trip type	Package Self-organised
Other
Holiday type: (select all that apply)	Package Self-organised Backpacking Camping Cruise boat Trekking
Please state

I'll be traveling
Accommodation: (select all that apply)	Hotel Relatives Family / friend home Youth hostel Tent Other
Staying in Areas: (select all that apply)	Urban Rural Altitude
Activities: (select all that apply)	Safari Adventure Other

Your health history – current and past

Do you have or have you ever had any of these medical problems? Please select all that apply.

Asthma
Chronic lung disease
Tendency to chest infections
Diabetes
Stomach ulcer
Irregular heartbeat
Joint problems
Psoriasis
Heart disease
Blood clotting disorders
Weakness of the immune system
HIV/AIDS
Mastectomy
High blood pressure
Mental illness (incl anxiety/panic)
Splenectomy
Liver disease
Epilepsy
Kidney disease
Cancer

Any other medical problems?


Please specify:

Are you currently taking any kind of medication?

(eg contraceptive pills, antibiotics)


Please specify:

Do you have any allergies?


Select all that apply	Eggs Bees stings Sulphur drugs Penicillin / neomycin Iodine Latex Band aids Other Please specify How do you react?

Have you ever had a serious reaction to a vaccine given to you before?


Please specify:

Other reactions and conditions

Have you ever felt faint or fainted after an injection or giving blood?	Yes No
Women only: Could you be pregnant now OR do you plan to become pregnant within 3 months of your return?	Yes No
Are you in contact with anyone with a weakened immune system? Eg people with HIV/AIDS, cancer sufferers on chemotherapy, people taking steroid drugs	Yes No

Vaccination or disease history (with date mm/yyyy)

Have you had or been vaccinated for any of the following?

Tetanus	No Yes Date
Typhoid	No Yes Date
Meningitis	No Yes Date
Rabies	No Yes Date
Varicella	No Yes Date
Hepatitis A	No Yes Date
Hepatitis B	No Yes Date
Yellow Fever	No Yes Date
Jap Enceph	No Yes Date
Whooping Cough	No Yes Date
Mumps	No Yes Date
Polio	No Yes Date
Influenza	No Yes Date
Measles	No Yes Date
Malaria Tabs	No Yes Date

Any additional information or travel health concerns?

Please specify