Thai Travel Clinic.com - The Special clinic for Travelers' health in Thailand.



	Travel Clinic - Health Questionnaire Hospital for Tropical Diseases, Faculty of Tropical Medicine, Mahidol University .

Name: Age: Date of Birth:

SEX: Male Female Address: City:

Country: Tel No:

Email address: (Please specify)

PART 1 Basic Traveling information and Medical Background

Departure date from your home country:

Return Date:

Please indicate the country that you've visited before Thailand on this travel,
Country	Length of stay Rural Urban
Country	Length of stay Rural Urban

Please indicate your next destination after leaving Thailand

Country	Length of stay Rural Urban
Country	Length of stay Rural Urban

How long have you been here in Thailand ?

How long will you stay in Thailand ?

Which province do you plan to travel to?

What is the purpose of your travel plan ? Travel Business/Work Visit Friend Other

Do you have any medical conditions such as diabetes, heart/lung disease?

No Yes

Are you being treated for cancer, or any other malignancy disease?

No Yes

Do you have a history of deficiency of the immune system?

No Yes

Are you on steroids, predisone, or cortisone for any reason?

No Yes

For FEMALE only :

	Are you pregnant or trying to become pregnant?
	Are you on breast feeding?

No Yes

Are you allergic to any of following?

	Drug please specify Vaccination please specify Other vaccine component (egg, yeast, gelatin, bee/insect sting, soy, lactose) No, I never had any allergic history to any known substance

List all medications you currently are taking, either prescriptions or over-the counter:

PART 2 Special Concerned in this Visit

Reason for visiting our Travel clinic

Need advice about malaria protection and prophylaxis
Need advice about traveller's diarrhea
Need health check up and/or health certificate
Need immunization , please specify

Have you had any of the following travel vaccines or medication ?
	Typhoid- oral or injectable Complete course Yes No last dose
	Hepatitis A Complete course Yes No last dose
	Hepatitis B Complete course Yes No last dose
	Flu vaccine Complete course Yes No last dose
	Polio- oral or injectable Complete course Yes No last dose
	Yellow Fever Complete course Yes No last dose
	Tetanus Toxoid Complete course Yes No last dose
	Japanese Encephalitis Complete course Yes No last dose
	Meningococcal Complete course Yes No last dose
	Antimalarial drug last dose

If you ‘re sick do you have the symptoms of

Fever Diarrhea Insect or animal bite Other symptoms, please specify

Please describe your symptoms and your illness:

How do you know about our service?

Friend / Relative

Internet please specify website

Airline

Guidebook

Leaflet/brochure

Hospital/Clinic

Other