Consultation Form

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Abbotsford Travel Clinic Travel Consultation Vaccination Chilliwack Travel Clinic

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Emergency Contact

Itinerary

Health History

Any allergies for example to eggs, antibiotics, nuts or latex?

Have you had a serious reaction to a vaccine given to you before?

Does having an injection make you feel faint?

Do you or any close family members have epilepsy?

Do you have any history of mental illness?(for malaria treatment)

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

If you answered yes to any of the last 4 questions, please explain:

Are you pregnant, planning pregnancy or breastfeeding?

Vaccination History

Please select previous vaccines

Cholera

Hepatitis A

Hepatitis B

Japanese encephalitis

Measles-Mumps-Rubella

Meningococcal meningitis

Polio

Rabies

Tetanus-Diphtheria

Typhoid

Yellow Fever

Unsure Speak to Pharmacist

You can also upload a screenshot or a scan of your previous vaccination records

Upload File

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By signing and submitting this form I confirm the information provided is accurate and I give permission for Caresol Travel and partner pharmacy to use this information to assess and advise on my travel health need.

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