Pre-Travel Worksheet

*Required fields to be completed for us to process your travel requirements. One form per person

*Date: / *GP:
*Last Name: / *First Name:
*Gender: / *DOB: / *Weight in Kgs:
*Address:
Phone: Home / Work: / Other:
*Email Address:
Travelling on your own:
If no please stipulate who you are travelling:
Please choose appropriate answer:
Travel Reason:
Will you be:
*Departure Date from NZ: / *Returning date to NZ:
*Allergies (Tick): / Aspirin ☐ / Penicillin ☐ / Sulpha’s ☐ / Triprim
☐ / Tetracycline’s ☐ / Codeine
☐
Other
☐ / No Allergies
☐
Previous immunisations and dates:
Tetanus: ☐ / Polio: ☐ / Hepatitis A: ☐ / Hepatitis B: ☐
Typhoid: ☐ / Measles: ☐ / Mumps: ☐ / Rubella: ☐
Yellow Fever: ☐ / Meningitis: ☐ / Rabies: ☐ / Japanese Encephalitis: ☐
Current medications including self prescribed:
*Egg Allergy:
Important past/current medical problems: (please tick )
Heart Disease: ☐ / Liver Disease: ☐ / Kidney Disease: ☐ / Epilepsy: ☐
Skin disease or Photosensitivity: ☐ / Candida(Thrush): ☐ / Eye Disease: ☐
Gastrointestinal Disease: ☐ / Blood Disease: ☐ / Gout: ☐
Other: ☐ / Please Specify Other:
Females only:
Pregnant . / Number of Weeks:
Breastfeeding:
Oral Contraceptive: / Name:
Please supply detailed travel itinerary over the page
Please return this form as soon as possible to or post to the above address
Malaria Prophylaxis – if needed please tick your preference:
Doxycycline ☐ / Malarone ☐ / Mefloquine ☐
Detailed Itinerary
Region to be visited: (2 examples) / Date of stay: / Accommodation type: / Transport:
A: Vietnam / Ho Chi Minh 1-6 JulyDa Nang 7-10 July Hanoi 11-12 July / Budget hotelHostel Friends / Local Buses
B: Peru / Cusco 1-4 AugustMachu Picchu 5-6 August Puno 7 August Lake Titicaca 8-10 August Lima 12/14 August / 3 Star HotelCamping Backpacker Hotel Aymara Family Youth Hostel / PlaneInca Trail Bus Reed Boat Train
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