Pre-Travel Assessment
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1. About You
Full Name
*
This field is required.
Date of Birth
*
Format: DD/MM/YYYY
This field is required.
Email Address
*
This field is required.
Contact Phone Number
*
This field is required.
Have you ever received any medical services at Professional Services Centre
Select an option
Yes
No
Not sure
2. Your Trip
Destination Country / Countries
*
This field is required.
Specific regions or cities being visited (if known)
Departure Date
*
Format: DD/MM/YYYY
This field is required.
Return Date
*
Format: DD/MM/YYYY
This field is required.
Purpose of Travel
*
Select an option
Leisure / Holiday
Business
Visiting Family or Friends
Study
Volunteering / Mission Work
Other
This field is required.
Type of travel / planned activities (select all that apply)
City stay
Rural or village travel
Trekking / hiking
Safari / wildlife
Cruise
Backpacking
Extended stay / living abroad
Other
Accommodation Type
Select an option
Hotel / Resort
Rural guesthouse
Camping
Staying with family or friends
Other
3. Your Health
Do you have any existing medical conditions? If yes, please list them.
Optional — you're welcome to discuss this with your doctor in person instead.
Are you currently taking any regular medication? If yes, please list.
Do you have any known allergies (medication, food, or other)?
Have you had any reactions to vaccinations in the past?
4. Vaccination History
As far as you know, are your routine vaccinations up to date?
Select an option
Yes
No
Not sure
Please list any travel vaccinations you’ve had before, and roughly when, if known.
Do you have a vaccination record or certificate?
Please bring it with you to your consultation — no need to upload anything here.
Select an option
Yes, I'll bring it to my appointment
No
Not sure
5. Before You Go
Are you travelling with children?
Select an option
Yes
No
If yes, please give their ages
Anything else you’d like your doctor to know before your consultation?
I consent to Professional Services Centre collecting and holding the information in this form in order to prepare for my Travel Clinic consultation.
*
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