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Travel Health Questionnaire

YVESAM LTD > Travel Health Questionnaire

TRAVEL HEALTH CLINIC

At YVESAM LTD, we aim to provide the best possible health consultation tailored to your individual needs. Please take a few minutes to complete this questionnaire, so we can better understand your health concerns and recommend the most suitable service for you.

Step 1 of 5 - Your Personal Details

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TRAVEL HEALTH CLINIC
Name*
First Last
Age*
Date of birth*
DD slash MM slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Sex *
- Male
- Female
- Prefer not to say
- Other
Consultation date *
DD slash MM slash YYYY
GP Surgery *
Do you give consent for this consultation?*
- Yes
- No

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TRAVEL ITENARY
Country visiting*
Arrival Date*
MM slash DD slash YYYY
Departure date *
MM slash DD slash YYYY
What sort of places are you staying *
- Staying in a hotel
- Local or rented accommodation
- Camping
- Staying on a cruise ship
- Staying with friends or relatives
- Staying at a backpacker hostel or bed and breakfast accommodation
- Staying at a refugee camp or volunteer centre
- Other:
Reason for travel and activities? (Tick all that apply)*
- Business travel
- Holiday
- Student gap year / backpacker
- Volunteer work / missionary work
- Possibility to be sexually promiscuous
- Diving
- Expatriate
- Hajj or other pilgrimage
- Visiting friends or relatives
- Adventure
- Adventure sports or extreme activities (for example remote trekking, motorcycling or cycling)
- To receive medical treatment
- Visiting high altitude areas
- Refugee / natural disaster
- Other Activities
- Other:

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Tailor your travel consultation
The following protection will already be included in this consultation.*
- DTP (diphtheria tetanus poliomyelitis)
- Hepatitis A
- Dengue Fever
- Japanese encephalitis
- Typhoid fever
- Hepatitis B
- Cholera
- Tuberculosis
Additional options You can select the following options to be covered as part of the consultation as well:*
- Jet lag medication
- Medication for altitude sickness
- Traveller's diarrhoea stand-by treatment
- Vaccination for measles, mumps and rubella (MMR)
- I confirm the patient doesn't require extra protection

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MEDICAL HISTORY/CONDITIONS
Indicate if you have any of the following. Tick all that apply*
- Diabetes
- Asthma
- Kidney problems
- Sickle cell
- Phenylketonuria
- High blood pressure
- Cerebral disorder (e.g. epilepsy, stroke)
- Liver problems
- Porphyria
- Myasthenia gravis
- Other ongoing medical condition(s)
- No ongoing medical conditions
Provide details of any ongoing medical problems.*
Are you currently taking any prescription medications?*
- Yes
- No
Please list dose and frequency (Failing to provide accurate information may delay the process)*
Are you taking any regular medication which thins your blood or prevents it from clotting, excluding aspirin 75mg?*
- Yes
- No
Do you have a bleeding disorder, including taking any medication that thins your blood (anticoagulants)?*
- Yes
- No
Have you received oral or parenteral antibiotics within the last 14 days?*
- Yes
- No
Have you had a high fever or temperature in the last 24 hours?*
- Yes
- No
Are you immunosuppressed due to disease or treatment?*
- Yes
- No
Have you had any operations in the last six months?*
- Yes
- No
Would you prefer to have an oral vaccination instead of an injection where available?*
- Yes
- No
Have you been told by your doctor you have an intolerance to any sugars, (e.g. galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption)?*
- Yes
- No
Are you suffering from constipation, abdominal pain, vomiting or any other digestive problems?*
- Yes
- No
Have you recently had diarrhoea after having an antibiotic medicine?*
- Yes
- No
Have you ever suffered/do you currently suffer from depression, anxiety, panic attacks or any other psychiatric problems? Please answer yes even if the episode was mild or an isolated case.*
- Yes
- No
Do you have a known or suspected cancer, or have you had cancer in the past?*
- Yes
- No
Have you received any live vaccines in the last 4 weeks?*
- Yes
- No
Do you have any bone marrow problems or blood disorders (e.g. blood dyscrasias)?*
- Yes
- No
Are there any other health/medical details you feel we should know?*
- Yes
- No
Do you have or have you ever had any allergies?*
- Yes
- No
Have you ever had an allergic or anaphylactic reaction to a vaccine before? **
- Yes
- No

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DENGUE FEVER QUESTIONS
Have you previously been infected with dengue?*
- Yes
- No
Have you lived or spent extended periods in a dengue-endemic area?*
- Yes
- No
Have you had antimalarials before?*
- Yes
- No
Have you reacted to any antimalarials before?*
- Yes
- No
PATIENT VACCINE RECORD
NAME OF VACCINE
RECOMMENDED VACCINES,BATCH NUMBER AND EXPIRY DATE
VACCINES *
DATE BATCH
MM slash DD slash YYYY
EXPIRY DATE
MM slash DD slash YYYY
SITE AND ROUTE OF INJECTION (INTRAMUSCULARLY)
- LEFT ARM
- RIGHT ARM
- LEFT THIGH
- RIGHT THIGH
Name
This field is for validation purposes and should be left unchanged.

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At YVESAM LTD, we are dedicated to providing expert health consultations tailored to your needs. Whether you require private health consultations, travel health advice, weight loss solutions, or general medical guidance, our experienced team ensures personalized and professional care.

Contact Info

+44 7880 226580
info@yvesamltd.co.uk
8:00 - 17:00

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