Pre-Travel Assessment Form

Fill Out the Online Form

We encourage you to book your consultation at least 6–12 weeks prior to departure, as some immunizations and medications must be started well before travel, and to allow adequate time for personalized research and preparation. Please be prepared to provide detailed travel information, including dates and all destinations, along with an up-to-date record of your immunizations and vaccinations — it may be time to call Mom and find that yellow card!

"*" indicates required fields

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Name

This field is for validation purposes and should be left unchanged.

Personal Details

Name*

First Last

Date of Birth*

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Current Age*

Address*

Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code

Gender*

Please select…MaleFemaleOther

Home Phone*

Work Phone

Email*

Weight*

Family Doctor*

Personal Medical History

Are you pregnant or breastfeeding?*

Please select…NoYes

Do you have a weakened immune system?*

Please select…NoYes

Is your health generally good?*

Please select…NoYes

Have you ever fainted or felt unwell after an injection?*

Please select…NoYes

Any serious reaction to a vaccine?*

Please select…NoYes

Any vaccines in the last month?*

Please select…NoYes

Are you currently taking any steroid medications?*

Please select…NoYes

Are you allergic to eggs, any antibiotics, or latex?*

Please select…NoYes

Are you travelling with young children?*

Please select…NoYes

Are you doing charity work overseas?*

Please select…NoYes

Such as refuges camps, missionary work

Does anyone in your household have a lowered immune system?*

Please select…NoYes

Do you have history of mental illness such as depression or anxiety?*

Please select…NoYes

Have you suffered from any of the following?

Jaundice/hepatitis

Blood clots

Ear/hearing problems

Cancer/chemotherapy

HIV/AIDS

Diabetes mellitus

Heart disease

Medications & Conditions

Please list all current medications

Add Remove

Include both prescription or over-the counter

Please list any allergies or intolerances (reaction)

Add Remove

Please list any other medical conditions

Add Remove

Immunization History

Are your regular immunizations up to date?*

Please select…YesNoNot Sure

When was the date of your last tetanus shot?

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YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Have you had the following vaccines?

Annual influenza

COVID-19

RSV

Pneumonia

Shingles / zoster

MMR

Have you ever received the following travel vaccines?

Hepatitis A

Hepatitis B

Rabies

Yellow fever

Japanese encephalitis

Ticke borne encephalitis

Typhoid

Dukoral

Meningitis

Trip/Travel Details

Date of departure from Canada*

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YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Date of return to Canada*

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DayDay12345678910111213141516171819202122232425262728293031

YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920

Destination Details*

Country

Town/City

Urban/Rural?

Accommodations

Time spent in country

 

Add Remove

Your Travel Experience*

Please select…New travellerLocal trips, never overseasTravelled overseasExperienced traveller

Holiday Type*

Please select…Independently arrangedCampingCruise shipBackpacking/trekking

Reason for travel*

Please select…BusinessPleasureOther

Accommodation type (most common)*

Please select…Hotel/ResortHostelsFriends/family homeCamping

Who is travelling with you?*

Please select…SoloWith family/friendGroup

Are any of the following activities included in your trip plans?

Scuba diving

Adventure travel

High altitude

Time spent in rural communities

Safari/jungle

What are your primary concerns with your trip or this travel health assessment?

Getting sick while away/travellers’ diarrhea

Who to contact while away in the case of emergency

Safety and efficacy of vaccines

Personal safety

Antimalarial medications

Tips to lower risk of getting risk or hurt

LGBTQ+ travel concerns

Are there other concerns you have that were not discussed on this form?

Consent

Confidentiality Statement: All personal and medical information provided on this form is strictly confidential and will be used solely for the purpose of assessing your travel health needs. Your information will only be shared with authorized healthcare professionals involved in your care and will not be disclosed to any third parties without your consent, except as required by law.

Consent*

I confirm that I have received medical clearance, based on my medical comorbidities, to travel from my primary care provider. I also give consent to receive a travel service from a remote physician / Dr. Jeff Remington.

Today's Date*

MM slash DD slash YYYY

Signature*

Also, you may print and complete our Pre-Travel Assessment Form and bring it to the pharmacy counter at Boggio and Edwards IDA Pharmacy in Ridgeway, Ontario. You may also call to schedule an appointment and then fax or email the completed form in advance.

Click here for PDF Pre-Travel Assessment Form