Travel Clinic Screening Questionnaire

Please fill out the form below to book your travel vaccinations

Are you any of the following?

PLEASE NOTE:

If you have ticked "YES" to any of the boxes above, the information you have provided indicates you are not eligible for this service, as you are more at risk of severe illness. We recommend you see a doctor for an assessment of your illness.

If you have answered "NO" to all the questions above, please proceed to the travel assessment questions below.

Who are you filling this form out for? (Please fill in a form for each individual)

Full Name

Date of Birth

Gender

New Zealand Address

City

Post Code

Cell Phone Number

Email

Date of Departure

Date of Return

Please provide a full list of intended destinations (country, region etc) and length of time in each place

Purpose of your trip? E.g. holiday, business, volunteer, etc

Are you travelling alone, with family/friends, or in a tour group?

Intended accommodation type/s eg, hotel, hostel, homestay, camping, air conditioned etc

Please specify what types of places you will be visiting? Rural, urban, jungle, coastal mix etc

Previous travel experience? Any significant problems or health issues during this travel?

Please list any previous travel vaccines

Please provide information about any planned activities you intend to experience, e.g. sightseeing, skiing, cycling, hiking, water sports. Do you intend to participate in any high-risk activities such as climbing/mountaineering, diving, sky diving (please note that we recommend patients seek advice from a specialist travel doctor for travel advice and support with these activities)

Please provide information about your general health, any regular or prescribed medications you may take, and if you have any medication allergies

Do you have any medical concerns about this trip, or is there anything specific you would like to discuss?

Are there specific travel accessories or aids that you wish to purchase or need?

Do you have travel insurance?

Address

Message Sent.

Our Opening Hours

Monday - Friday
9.00 AM - 5:30 PM

Saturday
9:00 AM - 2:00 PM

Sunday
Closed

Contact us

Phone:
03 326 6154

Email:
info@sumnerpharmacy.co.nz

Address:
Sumner Pharmacy
17 Wakefield Avenue,
Sumner,
Christchurch 8081

TRAVEL CLINIC SCREENING QUESTIONNAIRE

Please fill out the form below to book your travel vaccinations

Are you any of the following?

PLEASE NOTE:

Our Opening Hours

Contact us

Send us a message

TRAVEL CLINIC SCREENING QUESTIONNAIRE

Please fill out the form below to book your travel vaccinations

Are you any of the following?

PLEASE NOTE:

Our Opening Hours

Contact us

Send us a message

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