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

c)   Never

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

d)   Typhoid

e)   Japanese encephalitis

f)    Rabies

g)   Avian Flu

h)   Seasonal flu

i)     Malaria

j)    Yellow fever

k)   Bird flu

l)     Dengue

Q7. Which of the following medical conditions are you suffering from or have a history of?

a)   Heart conduction abnormalities

b)   Radical mastectomy

c)   Chemotherapy

d)   Psoriasis

e)   Kidney ailments

f)    Liver ailments

g)   Seizures

h)   Depression

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

Yes

No

Pregnancy stage:____________

Category: Travel Questionnaire