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:
| Country | Weeks | |
|---|---|---|
| 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: | |||