Travel Clinic Questionnaire
The primary objective of the travel clinic questionnaire is to assimilate medical information of a traveler. This type of questionnaire is normally filled by a traveler before leaving for their travel destination and is mandatory. The information is gathered and checked by the local clinic, the government health department, and immigration officials.
Travel Clinic Questionnaire Sample
Name of the traveler___________________________________________
Address of the traveler: ______________________________________
City: ________________ State: ___________________ Zip: _________________
Telephone: ____________________ Fax: ____________________________
Age: _________ Sex: ___________ Date of Birth: ______________________
Last checkup date: ____// _____// ______ Name of the Physician: ____________________
Visiting Destination: _________________ Date of Departure: ____// _____// ______
Duration of Stay: _____________ Purpose of the trip: ____________________
Q1. How often do you travel outside the country?
a) Once a month
b) Once every quarter
c) Once in 6 months
d) Once in a year
e) More than 12 trips in a year
Q2. Do you take medical tests and get necessary check-ups every time you are traveling abroad?
a) Every time
b) Some times
Q3. Which over the counter and prescribed medications are you taking currently?
Q4. What food allergies do you have?
Q5. What type of medication are you allergic to?
Q6. Which of the following vaccinations have you been administered with?
a) Routine vaccines like tetanus, poliovirus etc
b) Hepatitis A or immune globulin
c) Hepatitis B
e) Japanese encephalitis
g) Avian Flu
h) Seasonal flu
j) Yellow fever
k) Bird flu
Q7. Which of the following medical conditions are you suffering from or have a history of?
a) Heart conduction abnormalities
b) Radical mastectomy
e) Kidney ailments
f) Liver ailments
i) Other psychiatric conditions
j) Thymic gland disorders
k) Back problem
l) High altitude problems
m) Travelers’ diarrhea
Q8. Are you currently pregnant? If yes, mention pregnancy stage
Category: Travel Questionnaire