International Travel Questionnaire
Please return this completed form prior to your appointment. Please note Travel Medicine is not a covered benefit of MSP.
Consultation and vaccination costs are the responsibility of the patient. There will be a fee charged for all appointments cancelled
with less than 24 hours notice. Please ensure that the vaccination history is completed, and bring all vaccination documents to
your appointment, as this information is require for the consultation. North Shore Health may be able to provide vaccination
history. They can be contacted at 604-983-6700
Name:
Date of birth:
Date of departure:
Country of Travel
Specific Region
General Medical
Duration of stay
Yes
No
Notes
Have you ever fainted from having your blood drawn?
Have you ever had a fever reaction to a vaccination?
Have you had any bad reactions/side effects from any
Vaccinations?
Do you live (or work closely) with anyone who has AIDS,
and AIDS-like condition, or any other immune disorder, or
who is on chemotherapy for cancer
Do you have a family history for cancer?
Have you ever received any injections of immune globulin
or any blood product during the past 12 months?
Do you have a medical condition that is stable now, but
that may recur while travelling?
Do you have a medical condition that warrants
maintenance medications or physician follow-up?
Have you had a fever in the last 48 hours
Are you pregnant or might you become pregnant on this
trip?
Are you breast feeding?
Do you have AIDS or and AIDS-like condition, any other
immune disorder, leukemia, or cancer?
Have you ever had your thymus gland removed or a
history of problems with you thymus, such as myasthenia
gravis, Di George syndrome, or thyoma?
Do you have severe thrombocytopenia (low platelet count) or a
clotting disorder?
Continuum Medical Care
201-520 17th Street, West Vancouver, BC, V7V 3S8
Tel: 604.913.8183, Fax: 604.913.8804
General Medical
Have you ever had a convulsion, seizure, epilepsy,
neurologic condition, or brain infection?
Yes
No
Comments
Do you have any stomach or bowel conditions?
Do you have severe kidney impairment?
Have you ever had hepatitis or jaundice?
Do you have a history of psychiatric problems?
Do you have problems with vaginal yeast infections?
Do you have psoriasis?
Have you or a member of your household ever been
diagnosed with eczema or atopic dermatitis (itchy, red,
scaly rash lasting > 2 weeks that often comes and goes)?
Do you have cardiac disease, with or without
symptoms?
Do you have any eye conditions?
Are you allergic to eggs?
Are you allergic to any to other products, eg: latex,
gelatin, soy, lactose?
Please list your current medications
Please list any medications you are allergic to
Vaccination History (Bring all documentation to your appointment)
Vaccine Type
Date given
Vaccine Type
Tetanus/diphtheria
Meningitis
Polio
Japanese Encephalitis
MMR
Yellow Fever
Adacel
Dukoral
Hepatitis A
Influenza
Hepatitis B
Pneumococcal
Typhoid
Rabies
Travel information is provided in pdf format unless otherwise requested
I would prefer the information in paper format
Continuum Medical Care
201-520 17th Street, West Vancouver, BC, V7V 3S8
Tel: 604.913.8183, Fax: 604.913.8804
Date given