In order to facilitate the consultation, please complete the
QUESTIONNAIRE on this page and on page 2:
q
Which country(ies) will you be visiting? ฌ
ญ
.
.
ฎ
.....ฏ
..
ฐ
..
q
What is the date
of departure?
/
/
q
How long will
you stay abroad?
.
days/weeks/months/years
q
Will you be
travelling alone? in a group? with
family?
q
What kind of
trip are your going to make? q business trip q family visit
q tourist trip q adventure trip q poor accommodations q living/working/training
q
Special
activities planned (diving, mountaineering, trekking)
q
Have you ever
travelled before?
q
Do you intend
to travel frequently in the future?
Health risks to travellers are closely related to the country of destination, the duration of stay, the mode of travel and your health status.
We consider four different ways of travelling:
1. Business trip or family visit: very comfortable, with good hygiene.
2. Tourist trip: well organized, very comfortable and confined to the
classical sites.
3. Adventure trip: organized across isolated areas, low-budget hikers, different
travel, long trips covering several countries ํ as a rule all trips lasting longer than 3 weeks; also foreigners visiting their native country.
4. Extended stay: work contracts of one or two years.
The doctor will give you advice in accordance with your own personal
situation. It is therefore important to answer the following questions:
When were
you last vaccinated against :
Yellow fever q never q less than 10 years ago q more than 10 years ago
Tetanus q never q less than 10 years ago q more than 10 years ago
Diphtheria q
never q
less than 10 years ago q
more than 10 years ago
Polio q
never q
less than 10 years ago q
more than 10 years ago
Hepatitis
A q never q 1 q 2 (q 3 )
booster(s)/ q
latest booster on
...
Hepatitis
B q never q 1 q 2 q 3 (q 4 ) booster(s)/
q latest booster on.
Typhoid
fever q
never q
less than 3 years ago q
more than 3 years ago
Meningococci
ACWY q
never q
less than 3 years ago q
more than 3 years ago
Measles q
never q 1 q 2 injections
q Have you ever had jaundice (hepatitis A)? Have you ever had measles? Yes/no
q Did you ever faint or pass out during previous vaccinations? Yes/no
q
Are you allergic to any drugs, vaccinations or any of their components, or to eggs? yes/no
(allergic = generalised rash, swelling of
mouth or throat, breathing problems)
Which drugs /
vaccine(s) :
q
Are you pregnant ? yes/no Do you
take the pill ? yes/no Do you
breast-feed ? yes/no Are you thinking
of getting pregnant within three months after the trip? yes/no
q
Are you taking medications ? If so, which ?
.....
- to suppress the production of gastric acid?.......................................................................
- For the heart ? For cardiopulmonary problems?
For blood coagulation
..
- Antiepileptics ? Antidepressants ? Sedatives
or sleeping tablets ?
....
...
- Psoriasis, eczema ? rheumatism ?
.
.
- Corticosteroids ?
Other immuno-suppressive medication ?
.......
.
q
Did you undergo an organ transplant ? Are you HIV-seropositive ?
q
Do you suffer from depression, anxiety
attacks or other serious mental problems?
q
Do you (frequently) take any stimulants such as alcohol?
Drugs?
The diseases most commonly seen in travellers are diarrhoea, fevers (malaria if you travel in a malaria-infested area), dengue/chikungunya; influenza), bronchitis, accidents (when travelling by car or
swimming), wound infections and sexually transmitted diseases.