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 :
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.