Pre-Travel Health Questionnaire

✈️ Welcome to Your Travel Health Questionnaire

📝 To help us plan the best recommendations for your consultation, it's essential that you complete this form with information about yourself and your trip.

⏰ Please fill it out as early as possible to ensure we have enough time to prepare everything you need.

Thank you for your cooperation! 🌍💉

👤 Personal Information

Please provide your personal details below:

Name *

First

Last

Email *

Email

Confirm Email

Phone Number *

Country of Origin

Age *

Occupation

🌍 Travel Information

Please provide the details of your trip:

Departure Date: *

Duration of Trip (in days): *

Region(s) of Travel: *

Countries and Duration in Each: *

Type of Trip *

Please Specify *

💉 Vaccination Requirements

Vaccines Required (if known):

separate with comma

Optional Vaccines (if known):

separate with comma

⚕️ Medical Background

What is your biological sex? *

Female
Male
Other
Prefer not to say

Are you pregnant or planning to become pregnant during your trip or within 3 months afterward? *

Yes
No

Are you breastfeeding or planning to during your trip? *

Yes
No

Have you recently had an infection (e.g., cold, flu, fever)? *

Yes
No

Please, provide details: *

Do you have any allergies (e.g., eggs, antibiotics, nuts)? *

Yes
No

Please, provide details: *

Have you ever had a serious reaction to a vaccine? *

Yes
No

Please, provide details: *

Do injections make you feel faint? *

Yes
No

Do you or close family members have epilepsy? *

Yes
No

Do you have a history of mental illness (e.g., depression, anxiety)? *

Yes
No

Have you recently undergone any of the following treatments? *

Radiotherapy
Chemotherapy
Steroids
None

Do you have travel insurance? *

Yes
No

If you have a medical condition, have you informed your insurer? *

Yes
No
Not Applicable

Are you requesting Malaria prevention tablets for your trip? *

Yes
No

💉 Vaccination History

Have you been vaccinated before? *

Yes
No

Have you ever received any of the following vaccinations? *

Diptheria
Hepatitis A
Hepatitis B
Influenza
Japanese B Encephalitis
Meningitis
Polio
Rabies
Tetanus
Tick Borne Encephalitis
Typhoid
Yellow Fever
Other

Diphtheria – if yes, please provide the date.

Hepatitis B – if yes, please provide the date.

Meningitis – if yes, please provide the date.

Rabies – if yes, please provide the date.

Typhoid – if yes, please provide the date.

Japanese Encephalitis (Type B) – if yes, please provide the date.

Hepatitis A – if yes, please provide the date.

Influenza – if yes, please provide the date.

Polio – if yes, please provide the date.

Tetanus – if yes, please provide the date.

Yellow Fever – if yes, please provide the date.

Tick-Borne Encephalitis – if yes, please provide the date.

What other vaccines have you been administered and when?

🔒RGPD

Checkboxes *

🔒 I hereby consent to the collection and processing of my personal data, which will be handled securely and in accordance with the Privacy Policy available at dronline.ie , in compliance with the General Data Protection Regulation (GDPR).

🙏 Thank you for your cooperation.

Wishing you a great consultation!

💻 Dr.Online

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