Travel Questionnaire

Prior to visiting our travel clinic, you are asked to fill out this questionnaire.

Your information will provide the public health nurse with your health history and assist them in preparation for your appointment.

Be as specific and detailed as possible.

Online Travel Questionnaire

* = Required

Clinic Information



No appointment? Email or call 905-688-8248 or 1-888-505-6074 ext. 7330.

Personal Information

Sex

* Birth date




* Itinerary

Departure date

Return date

List all countries and cities you will be visiting in order, and indicate if urban or rural (countryside).

Be as specific and detailed as possible.

Country City Arrival Date Urban / Rural
Nature of Trip

Additional Information

Provide us with any further details about your itinerary that may be important.

Health History

  • Which type?

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Allergies

Be sure to note any allergies to eggs, yeast, latex, gelatin, aluminum, thimersol or neomycin.

Allergy Type of reaction

Additional Information

Provide any details about your allergies that may be important.

Current Medications

Describe:

List any other medication you are currently taking

Medication Dosage Frequency

Vaccine Costs

Your Privacy: Use of Collected Information


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