Travel Clinic Screening Questionnaire

If you meet any of the criteria below or have any of the listed medical conditions, please contact Wellworks Pharmacy directly before completing this form. Assessment may require additional clinical review.

Contact Wellworks Pharmacy: 04 555 0522

Aged under 3 years
Pregnant, breastfeeding or planning a pregnancy within the next 3 months
Immunosuppression, recent chemotherapy, radiotherapy, immunosuppressive medications including daily prednisone, HIV
Complex medical history/severe medical condition/medically unstable
Only needing a Yellow Fever Vaccination

All members of your travel group, including couples and families, are required to complete individual forms.
Travel consultation fees start from $69, with discounts available for couples and families. See our price list for details.

Full Name

Date of Birth

Gender

New Zealand Address

City

Post Code

Mobile Phone Number

Email

Date of Departure

Date of Return

Please provide a full list of intended destinations (CITY, TOWN, country, region etc) and length of time in each place.

Purpose of your tip? E.g. holiday, business, volunteer etc.

Are you travelling alone, with family, friends, or in a tour group?

If you are travelling in a group, will other group members also require Wellworks Pharmacy Travel Clinic Services?

Intended accomodation type/s, hotel, hostel, homestay, camping, air conditioned etc.

Please specify the type of places you will be visiting. Rural, urban, jungle, coastal etc.

Previous travel experience: Any significant problems or health issues during this travel?

Please list any previous travel vaccines

Who is your regular medical centre and/or travel clinic where you have previously received travel vaccines and medicines.

Please provide information about any planned activities you intend to experience, e.g. sightseeing, skiing, cycling, hiking, water sports. Do you intend to participate in high-risk activities such as climbing/mountaineering, diving, ski diving (please note that we recommend patients seek advice from a specialist travel doctor for travel advice and support with these activities)

Please provide information about your general health, any regular or prescribed medications you may take, and if you have any medication allergies.

Do you have any medical concerns about this trip, or is there anything specific you would like to discuss?

Are there any specific travel accessories or aids that you wish to purchase or need?

Do you have travel insurance?

I give consent for Wellworks Pharmacy Travel Clinic to access my vaccination and relevant medical records from my medical centre for the purposes of providing travel health services.

Address

Message Sent.

Our Opening Hours

Monday-Thursday: 8:30-6pm
Friday: 8:30-5pm
Saturday: 10-2pm
Sunday: Closed

Wellworks Pharmacy
Taranaki Street

75 Taranaki Street
Te Aro
Wellington

hello@wellworks.co.nz
Phone: 04 555 0522

WELLWORKS PHARMACY TRAVEL CLINIC SCREENING QUESTIONNAIRE

All members of your travel group, including couples and families, are required to complete individual forms.
Travel consultation fees start from $69, with discounts available for couples and families. See our price list for details.

Our Opening Hours

Wellworks Pharmacy
Taranaki Street

Send Us a Message

WELLWORKS PHARMACY TRAVEL CLINIC SCREENING QUESTIONNAIRE

All members of your travel group, including couples and families, are required to complete individual forms.Travel consultation fees start from $69, with discounts available for couples and families. See our price list for details.

Our Opening Hours

Wellworks PharmacyTaranaki Street

Send Us a Message

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All members of your travel group, including couples and families, are required to complete individual forms.
Travel consultation fees start from $69, with discounts available for couples and families. See our price list for details.

Wellworks Pharmacy
Taranaki Street