Health Plan GP Assist Service

GENERAL PRACTITIONER DETAILS

NAME:

FAX:

PHONE:

PRACTICE ADDRESS:

TRAVELLERS DETAILS

GIVEN NAME:

SURNAME:

SEX  FEMALE  MALE

DOB / /

OCCUPATION:

CONTACT PHONE #:





YOUR PAST HEALTH

Do you have any ongoing medical problems? (eg: asthma, diabetes, psoriasis, high blood pressure, stomach ulcer,

joint problems, anxiety, depression, chest infections, epilepsy or recurrent thrush)__________________ Yes No

If Yes, please specify: _______________________________________________________________

Have you ever had anxiety, depression, epilepsy, a mastectomy, splenectomy or any other serious

medical problems? _________________________________________________________________ Yes No

If Yes, please specify: ______________________________________________________________

Have you been a patient in a hospital in the last 6 weeks? __________________________________ Yes No

Have you ever had Hepatitis A infection (yellow jaundice)? ________________________________ Yes No

Do you take any regular medication? (eg. contraceptive pill, heart tablets etc) _________________ Yes No

If Yes, please specify: ______________________________________________________________

Are you currently on any other medications? _____________________________________________ Yes No

Are you allergic to anything? (Eggs, Iodine, Bee stings, Sulphur drugs, Penicillin, Latex, Bandaids)__ Yes No

If Yes, please specify: _______________________________________________________________

Are you prone to fainting after an injection or giving blood? _________________________________ Yes No

Are you breast feeding, pregnant or planning to become so within the next three months or while

on your trip?________________________________________________________________________ Yes No

Do you or anyone you are in contact with have a poor immune system? (eg: AIDS, Cancer,

Leukaemia, Newborns) _______________________________________________________________ Yes No

Have you had any vaccinations in the past month? (eg: cholera, polio etc) _______________________ Yes No

YOUR TRIP

Please list in order the countries that you intend visiting and how long you will spend in each:

CountryWeeks
1
2
3
4
5
6
7
8

Date leaving Perth: ___________________________ Place of Departure from Australia: ______________________________

Date leaving Australia: _________________________ Return Date to Australia: __________________________________

Is this your first overseas trip? Yes No If No, how many previous overseas trips?_______________________________

What is your main reason for travel? Relaxation Adventure Work

If participating in adventure activities please specify: _________________________________________________________________

Approximately what percentage of your time will be in:

Rural/Remote Areas ____________% Urban/Resort Areas ______________% Above 1000 meters altitude _________%

Main type of Accommodation? 4-5 Star Hotels Intermediate Basic

(2-3 Star, Work Site etc) (Backpacking, Camping)

How did you hear of this clinic? Travel Agent/Airline - Name of Travel Agent _____________________________

Friend/Relative Other (please specify) ___________________________

Once you have completed all of the questions please fax or post this form, along with your $16.50 payment to:

Travel Medicine Centre Perth

Ground Floor, 200 St Georges Terrace, Perth WA 6000

Fax 08 9321 0899

Please forward your credit card details if this is your payment option:

VISA

MASTERCARD

BANKCARD

Card Number: ________________________________________________________ Expiry Date: ____________________

Card Holders Signature: