Patient Travel Questionnaire

Please complete this form at least 8 Weeks prior to travel.

Where possible make an appointment at least 6 weeks before you travel.

A form should be completed for each person who will be travelling.

Please select the practice location most relevant to this Online Form submission:

Patient Details

Name

Address

Date of birth

NHS number

Home Telephone

Mobile Telephone

Country 1

Date of departure

Country

Cities

Rural Areas

Coast

Length of Stay

Country 2

Date of departure

Country

Cities

Rural Areas

Coast

Length of Stay

Country 3

Date of departure

Country

Cities

Rural Areas

Coast

Length of Stay

Country 4

Date of departure

Country

Cities

Rural Areas

Coast

Length of Stay

Medical History

Are you fit and well today

Details

Severe reaction to a vaccine before

Details

Tendency to faint with injections

Details

Any surgical operations in the past, including e.g. your spleen or thymus gland removed

Details

Recent chemotherapy/radiotherapy/organ transplant

Details

Anaemia

Details

Bleeding /clotting disorders (including history of DVT)

Details

Heart disease (e.g. angina, high blood pressure)

Details

Diabetes

Details

Disability

Details

Epilepsy/seizures

Details

Gastrointestinal (stomach) complaints

Details

Liver and or kidney problems

Details

HIV/AIDS

Details

Immune system condition

Details

Mental health issues (including anxiety, depression)

Details

Neurological (nervous system) illness

Details

Respiratory (lung) disease

Details

Rheumatology (joint) conditions

Details

Spleen problems

Details

Any other conditions?

Details

Women only

Are you pregnant?

Details

Are you breast feeding?

Details

Are you planning pregnancy in the next 6 months?

Details

Where have you researched the vaccines you requireWe recommend travelhealthpro.org.uk

From this research, which vaccines do you believe you require?

Information on any vaccines or malaria tablets taken in the past (please add date if given)

Tetanus/Polio/Diptheria

Typhoid

Cholera

Japanese Encephalitis

Tick Borne Encephalitis

MMR

Hepatitis A

Hepatitis B

Rabies

BCG

Influenza

Pneumococcal

Meningitis

Yellow Fever

Other

Malaria Tablets

Allergies

Please add any allergies (include food, latex and medication)

Medications

Please amend this as necessary (include prescribed, purchased or contraceptive pill)

Acute Medication

Repeat Medication

Other:

Further Information you wish to mention:

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