Pre-Travel Health Assessment Form

Personal Information
Name *
Name
Date of Birth *
Date of Birth
Home Phone
Home Phone
Cell Phone
Cell Phone
BC Residence
Emergency Contact *
Emergency Contact
Emergency Contact's Phone Number *
Emergency Contact's Phone Number
Medical History - Please click any of the below that apply. Do you have any of the following?
* All information will be kept confidential, and the server connection is encrypted.
History of Immunization
Are you up-to-date with routine immunization? *
Please indicate any travel vaccination (Hepatitis A, Hepatitis B, Typhoid...etc) that you have received in the past.
Medications
* All information will be kept confidential, and the server connection is encrypted.
Travel Information
Date of Departure *
Date of Departure
Purpose of Trip *
Urban or Rural Visit *
List any special activities you may be involved in:
Current Date *
Current Date
We will be contacting you soon to make an appointment.