Thai Travel Clinic

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

Please indicate your next destination after leaving Thailand

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) *

Have you ever get the following vaccine before?