Questionnaire in anticipation of a travel clinic Please complete this questionnaire to help us determine the best immunization IDENTIFICATION Family Name : First Name : Age : years. Gender : womanman Phone : Email : TRAVEL INFORMATION Date of departure : (respect the format "yyyy-mm-dd") Duration of travel : days.weeks.months. Destination : Cities / towns visited : Planned trips ? noyes Reason for travel : DistractionOccupationalOther HEALTH HISTORY Do you suffer from health problems ? noyes Do you take any medications ? noyes Have you ever experienced surgeries ? noyes Are you pregnant ? (if applicable) noyes Do you have any allergies ? noyes After receiving this questionnaire, a nurse will contact you and ask you to supplement the list of vaccines you received previously. By checking this box, I confirm my declaration. MANDATORY Protection of personal data Most of the information contained on the CMIPQ website be freely consulted without entering personal data. However, in some cases, the user must provide personal data. In this case the data are processed according to the law on the protection of privacy with regard to data usage reserved. In this regard, the CMIPQ specifically agrees that the use of the processed data is limited exclusively to the objective pursued. The CMIPQ agrees to keep strictly confidential and not to divulge, sell or disclose to third parties, by any means whatsoever, the information transmitted to it.