Name
Address: (street, city, postal code)
Weight (pounds or kg)
Provincial health care number
Family Doctor
Date of Birth (dd/mm/yyyy)
Gender Male Female
Telephone
Cell
Email
Women: Are you pregnant or breastfeeding? Yes No
Have you been told you have a weakened immune system? Yes No
Are you feeling well today? Yes No
Is your health generally good? Yes No
Have you ever fainted or felt unwell after an injection? Yes No
Any serious reaction to a vaccine? Yes No
Any vaccines in the last month? Yes No
Are you currently taking any steroid medications? Yes No
Are you allergic to eggs, any antibiotics, or latex? Yes No
Are you travelling with young children? Yes No
Are you doing charity work overseas? (refugee camps, missionary work) Yes No
Do you or a family member have epilepsy? Yes No
Does anyone in your household have a lowered immunity? Yes No
Do you have a history of mental illness such as depression or anxiety? Yes No
Have you suffered from:
Jaundice/hepatitis Yes No
Blood clots Yes No
Ear/hearing problems Yes No
Cancer/chemotherapy Yes No
HIV/AIDS Yes No
Diabetes Yes No
Heart disease Yes No
Please list any other medical conditions
Are your regular immunizations up-to-date? Yes No Not sure
Pharmacist will have access to immunization records from BC and Yukon.
If immunization record is from other provinces/territories, please bring records to consult.
Date of departure from Canada (dd/mm/yyyy)
Date of return to Canada (dd/mm/yyyy)
Country/Countries
Town/City
Urban/Rural
Accommodations
Time spent in country/countries
New traveller Local trips never overseas Travelled overseas Experienced traveller
Reason for Travel Business Pleasure Other:
Holiday Type Package Camping Self-organized Cruise ship Backpacking Trekking
Most common type of accommodation Premium hotel Budget hotel Hostels Friends/family home Camping
Who is travelling with you? Solo With family/friend Group
Are any of the following activities be included in your trip plans? (please check all that apply) Scuba diving Going to a high altitude Safari Spending time in rural communities Adventure travel Exposure to extreme heat or cold Jungle Other:
Getting sick while away Travellers’ diarrhea Safety and efficacy of vaccines Antimalarial medications Cost of medications and immunizations Who to contact if emergency occurs overseas Travel insurance Personal safety overseas Tips to lower your risk of getting sick or hurt overseas
Are there any other concerns that you have that were not discussed on this form? (Please specify)
