Travel Clinic Screening Questionnaire

If you meet any of the criteria below or have any of the listed medical conditions, please contact Ngatea Pharmacy directly before completing this form. Assessment may require additional clinical review.
Contact Ngatea Pharmacy: 07 867 7408

Aged under 3 years
Pregnant, breastfeeding or planning a pregnancy within the next 3 months
Immunosuppression, recent chemotherapy, radiotherapy, immunosuppressive medications including daily prednisone, HIV
Complex medical history/severe medical condition/medically unstable
Only needing a Yellow Fever Vaccination

All members of your travel group, including couples and families, are required to complete individual forms.
Travel consultation fees start from $69, with discounts available for couples and families. See our price list for details.

Full Name

Date of Birth

Gender

New Zealand Address

City

Post Code

Mobile Phone Number

Email

Date of Depature

Date of Return

Please provide a full list of intended destinations (CITY/TOWN, country, region etc) and length of time in each place

Purpose of your trip? E.g. holiday, business, volunteer, etc

Are you travelling alone, with family/friends, or in a tour group?

If you are travelling in a group, will other group members also require Ngatea Pharmacy Travel Clinic services?

Intended accommodation type/s eg, hotel, hostel, homestay, camping, air conditioned etc

Please specify what types of places you will be visiting? Rural, urban, jungle, coastal mix etc

Previous travel experience? Any significant problems or health issues during this travel?

Please list any previous travel vaccines

Who is your regular medical centre and/or travel clinic where you have previously received travel vaccines and medicines?

Please provide information about any planned activities you intend to experience, e.g. sightseeing, skiing, cycling, hiking, water sports. Do you intend to participate in any high-risk activities such as climbing/mountaineering, diving, sky diving (please note that we recommend patients seek advice from a specialist travel doctor for travel advice and support with these activities)

Please provide information about your general health, any regular or prescribed medications you may take, and if you have any medication allergies

Do you have any medical concerns about this trip, or is there anything specific you would like to discuss?

Are there specific travel accessories or aids that you wish to purchase or need?

Do you have travel insurance?

I give consent for the Ngatea Pharmacy Travel Clinic to access my vaccination and relevant medical records from my medical centre for the purpose of providing travel health services.

Address

Message Sent.

Our Opening Hours

Monday - Friday
9.00 AM - 5:00 PM

Saturday & Sunday
Closed

Contact us

Phone:
07 867 7408

Email:
ngateapharmacy@gmail.com

Address:
20 Orchard West Road
Ngatea
Waikato 3503
New Zealand

NGATEA PHARMACY
TRAVEL CLINIC SCREENING QUESTIONNAIRE

Our Opening Hours

Contact us

Send us a message

NGATEA PHARMACY TRAVEL CLINIC SCREENING QUESTIONNAIRE

Our Opening Hours

Contact us

Send us a message

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NGATEA PHARMACY
TRAVEL CLINIC SCREENING QUESTIONNAIRE