Travel Clinic Screening Questionnaire

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

Contact Tahunanui Pharmacy: 03 548 6495

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 (dd/mm/yyyy)

Gender

New Zealand Address

City

Post Code

Mobile Phone Number

Date of Depature dd/mm/yyyy)

Date of Return dd/mm/yyyy)

Please provide a full list of intended destinations (City, town, country, region etc.) and length of stay in each place.

Purpose of your trip? 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 Tahunanui Pharmacy Travel Clinic Services?

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

Please specific what types of places you will be visiting? Rural, urban, jungle, coastal mix 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 recieved travel vaccines and medicines?

Please provide information about any planned activities you intent to experience, e.g. sightseeing, skiining, cycling, hiking, water sports. Do you intend to participate in any high-risk activities such as climbing/mountaineering, diving, sky 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 Tahunanui 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.

Ready to Travel with Confidence?

Complete your Pre-Travel Screening Questionnaire today and get your personalised health plan within 48 hours.

It only takes a few minutes — and could save your trip.

Get expert travel health advice locally at Tahunanui Pharmacy.

Contact Tahunanui Pharmacy today to book your travel vaccine consultation.
Or book in-store with our friendly team.

Travel with confidence. Travel protected.

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Our Opening Hours

Monday - Friday: 8.30 AM–5:30 PM

Saturday: 10:00 AM–12:00 PM

CLOSED: Sunday and Public holidays

Our Services

Contact Us

Phone: (03) 548-6495

Email: medicines@tahunanuipharmacy.co.nz

Address:
11 Tahunanui Drive
Nelson 7011
New Zealand

Tahunanui 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.

Ready to Travel with Confidence?

Our Opening Hours

Our Services

Contact Us

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.