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Pre-Travel Assessment Form

Pleasecomplete the form below:






1. Personal Details



 

2. Personal Medical History

 

3. Medication Record

The pharmacist will perform a MedsCheck with all travellers prior to preparing the final travel plan. Please bring all prescription and non-prescription items with you to your consultation

 

4. Vaccination History (bring record with you to appointment)

Abbreviations: HPV - human papillomavirus; MMR - measles, mumps, rubella

 

5. Travel Itinerary

Please complete in chronological order of travel as it may influence which vaccines are required. List all towns, villages, cities, etc. to be visited as vaccination requirements may differ within the same country.

 





































 

6. Trip Details

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