Thai Travel Clinic - Health Questionnaire General Information Name Sex Male Female Age Date of Birth Nationality Occupation Home City Home Country Address in Thailand Email address Telephone number Basic Travel Information and Medical Background Main purpose of this trip Tourism Bussines Academic/Education Voluntary/Missionary work Visiting Friends/Relatives Others Depart your country on (DD/MM/YYYY) Expected return date (DD/MM/YYYY) Please indicate the country that you have visited before Thailand on this trip Country Length of stay Country Length of stay Please indicate your next destination after leaving Thailand Country Length of stay Country Length of stay How long have you been here in Thailand? How long will you stay in Thailand? Which province do you plan to travel to? General Health Information Do you have any medical conditions such as diabetes, heart/lung diseases? Yes No Are you being treated for cancer, or any other malignacy diseases? Yes No Do you have a history of deficiency of the immune system including HIV/AIDS? Yes No Are you on steroid, predisone or cortisone for any reason? Yes No Do you allergic to any medication, vaccines, vaccine component such as egg/neomycin.gelatin? Yes No List all of your allegic medication/vaccine (if any) List all medications you currently taking either prescription or over the counter Do you allergic to any vaccine? (if yes, please spcecify..) Do you allergic to any vaccine component? (egg, gelation, neomycin) For female only Are you pregnant or trying to become pregnant? Yes No Are you on breast feeding? Yes No Special concern of this visit Reason for visiting our travel clinic Need advice about malaria prevention Need vaccination Need health check up and certificate Need medical service since I am sick If you are sick please descripe your symptoms in the text box below If you need vaccination, please specify....... Have you ever get the following vaccine before? Travel vaccine Rabies vaccine No, never Yes, completed Yes, not completed Yes, need booster Hepatitis A vaccine No, never Yes, completed Yes, not completed Yes, need booster Hepatitis B vaccine No, never Yes, completed Yes, not completed Yes, need booster Japanese Encephalitis No, never Yes, completed Yes, not completed Yes, need booster Typhoid vaccine No, never Yes, completed Yes, need booster Meningococcal vaccine No, never Yes, completed Yes, need booster Yellow fever vaccine No, never Yes, completed Yes, need booster Cholera vaccine No, never Yes, completed Yes, not completed Yes, need booster General vaccine Tetanus toxoid No, never Yes, completed Yes, need booster Influenza vaccine No, never Yes, completed Yes, need booster Remark: Please read and accept term&condition, then click submit and you will see a confirmation message. Accept Terms of Services ReCaptcha Submit Thank you very much. We have received your registration form in our system. Please turn on javascript to submit your data. Thank you!
