THIS FORM IS FOR ENROLLED PATIENTS OF BURWOOD HEALTH ONLY.

If you are a Casual Patient (you attend another medical centre), please use the form for Casual Patients

ENROLLED PATIENTS - Travel Questionnaire

The information on this form will help our team identify the vaccines you may require for overseas travel. Please complete a separate questionnaire for every person travelling, including any children. A nurse will contact you with 5 business days.

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PERSONAL INFORMATION

Name(Required)

First Last

Address(Required)

Date of Birth(Required)

Email Address(Required)

Phone(Required)

TRAVEL DETAILS

Departure Date(Required)

DD slash MM slash YYYY

Return Date(Required)

DD slash MM slash YYYY

Who are you travelling with?(Required)

Purpose of your travel (ie. holiday, business, volunteer work, visiting friends and relatives, special high risk activities)(Required)

Are your travel plans booked yet? (ie. flights, accommodation, transfers, activities)(Required)

Destinations(Required)

Country

Town / Region

Urban / Rural

Accommodation

Duration

MEDICAL HISTORY

Medical History (Please list)(Required)

Are you up to date with your childhood vaccinations?(Required)

Yes

Unsure

Please give details of any conditions that may affect your travel plans (Pregnancy, Diabetes, Disability, Immunocompromised, Heart Condition, Blood Clots, Thymus or Spleen problems, HIV/AIDS or recent surgery:(Required)

Allergies (ie. Eggs, Antibiotics etc)(Required)

Current Medications (including oral contraceptives):(Required)

WOMEN ONLY - Are you pregnant, planning pregnancy or breast feeding? If relevant, the number of weeks pregnant at time of travel

PREVIOUS TRAVEL HISTORY

Have you had previous travel vaccines?

Yes

Please give details of any previous vaccinations and anti-malarial medications below:

BCG

Date Recieved

Comments (ie. side effects)

Cholera

Date Recieved

Comments (ie. side effects)

Covid-19

Date Recieved

Comments (ie. side effects)

Hepatitis A

Date Recieved

Comments (ie. side effects)

Hepatitis B

Date Recieved

Comments (ie. side effects)

Influenza

Date Recieved

Comments (ie. side effects)

Japanese Encephalitis

Date Recieved

Comments (ie. side effects)

Meningococcal Group A, C, Y, W

Date Recieved

Comments (ie. side effects)

Meningococcal Group B

Date Recieved

Comments (ie. side effects)

Meningococcal Group C

Date Recieved

Comments (ie. side effects)

Pneumococcal

Date Recieved

Comments (ie. side effects)

Polio

Date Recieved

Comments (ie. side effects)

Rabies

Date Recieved

Comments (ie. side effects)

Tetanus alone

Date Recieved

Comments (ie. side effects)

Tetanus, Diphtheria, Pertussis

Date Recieved

Comments (ie. side effects)

Tetanus, Diphtheria, Pertussis, Polio

Date Recieved

Comments (ie. side effects)

Typhoid

Date Recieved

Comments (ie. side effects)

Yellow Fever

Date Recieved

Comments (ie. side effects)

Other

Date Recieved

Comments (ie. side effects)

Anti-Malarial Medications

Date Recieved

Comments (ie. side effects)

REQUESTED TRAVEL VACCINATIONS

PLEASE CHOOSE ONE OF THE FOLLOWING OPTIONS:(Required)

ENROLLED PATIENT - I will only have the vaccinations I tick below, but a GP consult is needed for antimalarial or back pocket medications ($135 + Vaccinations)

ENROLLED PATIENT- I AM OVER 18 YEARS - and I will only have the vaccinations I tick below, thus GP consult is not needed ($80 + Vaccinations)

ENROLLED PATIENT - I AM UNDER 18 YEARS - and I will only have the vaccinations I tick below, thus GP consult is not needed ($55 + Vaccinations)

ENROLLED PATIENT - I AM UNDER 13 YEARS AND TRAVELLING WITH A PARENT - and I will only have the vaccinations I tick below, thus GP consult is not needed ($25 + Vaccinations)

ENROLLED PATIENT - I will require advice on what vaccinations I need for my travel ($135 + Vaccinations)

I require the following vaccinations:

Avaxim $125

Chicken Pox $110 per dose (2 DOSES REQUIRED)

Cholera (Dukoral) $80 per dose (2 DOSES REQUIRED)

Hepatitis A (Adult Dose) $125

Hepatitis A (Junior) $95

Hepatitis A & B (Adult Dose) $125 per dose (3 DOSES REQUIRED)

Hepatitis A & B (Junior) $95 per dose (3 DOSES REQUIRED)

Hepatitis B $90 per dose (3 DOSES REQUIRED)

Hepatitis A / Typhoid $205

HPV (Gardasil -9) $250 per dose (3 DOSES REQUIRED)

Flu Vaccine $30

Fluad Quad (Superflu) $40

Japanese Encephalitis $270 per dose (2 DOSES REQUIRED)

Meningitis ACYW (Menactra / Nimenrix) $150

Meningitis B (Bexsero) $165 per dose (2 DOSES REQURIRED)

Meningitis C $105

Measles / Mumps / Rubella $45

Pneumococcal: Pneumovax $130

Pneumococcal: Prevenar 13 $260

Polio $110

Rabies (Rabipur) Intramuscular (Rabies) $180 per dose (3 DOSES REQUIRED)

Shingles $390 per dose (2 DOSES REQUIRED)

Tetanus / Diphtheria / Pertussis (Boostrix) $70

Tetanus / Diphtheria / Pertussis / Polio $ 110

Typhoid $115

Please tick any information you would like to discuss during your consult:

Bite and sting avoidance

Travel certificate for medications

Food and water safety

Sexual health advice

Other

PRE-PAYMENT CONSENT

PRE-PAYMENT - I am aware that I will receive an invoice that will require payment before my travel vaccination request is processed and reviewed by a Health Provider at Burwood Health(Required)

I agree to the $80 pre-payment - I am aware that does not include the cost of my travel vaccinations

CONSENT

Consent(Required)

I certify that the answers I have provided are true to my knowledge, and the advice and vaccination recommendations I receive will be influence by the answers I have provided. I am aware that I may need to remain in the clinics for 20 minutes after the vaccinations.

FINANCIAL CONSENT

Financial Consent(Required)

I consent that I understand that the cost of the vaccinations recommended are additional to the cost of the consultation. I am also aware that I will need to pre-pay for both my travel vaccination consult and the recommended travel vaccinations.

Burwood Health

(03) 383 0219

Enrolled Patient – Travel Questionnaire

THIS FORM IS FOR ENROLLED PATIENTS OF BURWOOD HEALTH ONLY.

ENROLLED PATIENTS - Travel Questionnaire

PERSONAL INFORMATION

TRAVEL DETAILS

MEDICAL HISTORY

PREVIOUS TRAVEL HISTORY

Please give details of any previous vaccinations and anti-malarial medications below:

REQUESTED TRAVEL VACCINATIONS

PRE-PAYMENT CONSENT

CONSENT

FINANCIAL CONSENT

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