Remote Area Service Travel Health Plan
Best day(s) of week for us to contact you: Time (please nominate two hours): Between and 1. Have you travelled to less developed countries before? Yes ( ) No ( ) Did you have any health problems while away? Yes ( ) No ( ) If yes, please provide details below.
2. Do you have any medical problems? e.g. asthma, chronic bronchitis, tendency to chest infections, diabetes, stomach ulcer, psoriasis, joint problems, mastectomy, splenectomy, epilepsy, high blood pressure, depression, schizophrenia, anxiety attacks, mental illness, weakness of the immune system, HIV/AIDS, blood clotting disorders, thrombosis, pulmonary embolism, other? Yes ( ) No ( ) 3. Have you been in hospital in the last 6 weeks, or planning this in the next 6 weeks? Yes ( ) No ( ) 4. Have you ever had the disease Hepatitis A (Yellow Jaundice)? Yes ( ) No ( ) 5. Are you taking any medication now (e.g. contraceptive pill, antibiotics?) or do you occasionally take medication (e.g. migraine tablets, ventolin, vitamins) Yes ( ) No ( ) 6. Are you allergic to anything? E.g. sulphur drugs, eggs, penicillin, bee stings, iodine, neomycin, latex, 7. Have you ever felt faint or fainted after an injection or giving blood? Yes ( ) No ( ) 8. Women only: Are you pregnant or planning to become so within 3 months of your return? Yes ( ) No ( ) 9. Are you in contact with anyone with a weakened immune system e.g. people with AIDS, cancer sufferers on chemotherapy, people taking steroid drugs? Yes ( ) No ( ) If yes, please specify below.
10. Did you miss any of the usual childhood vaccines? Yes ( ) No ( ) If yes, please specify below. 11. Do you have any particular health concerns regarding this trip? Yes ( ) No ( ) 12. Please list in order the countries you intend visiting, and how long (in weeks) you plan to spend in each: 13. Reason for travel? (Please circle below): Recreation / Relocation / Honeymoon / Visit Relatives / Business / Aid a Community / Other 14. Type of accommodation? (Please circle below): Camping / Budget / Air conditioned hotel / Private home / Other 15. Will you be undertaking any adventure activities? (Circle) Trekking / Scuba diving / Climbing / Other Will you be coming through Adelaide (we may be able to arange vaccines eg Yellow Fever at last minute) If you have an international vaccination record book, you can send a copy of all the relevant pages – our doctors are very skilled at reading these books and knowing what all the vaccines are. If you do not have a vaccination book, please fill in the next page as best you can. You may need to contact your doctor for a printout or written vaccination record. NB You will be issued with an International Vaccination Record Book as part of this process so you will have Had the disease?
Primary Course
Date of last vaccine
Name of disease
If unknown put “?”
Option 1: Fax back to the Travel-Bug on 08 8239 2329 08 8239 2329
Option 2: Scan it and Email to
or Option 3: Post in sealed envelope to: Travel-Bug Vaccination Clinics PO Box 1144 North Adelaide SA 5006


Health services

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