Travel Health Questionnaire Please complete the form as fully as you can so that we can process your details efficiently. Step 1 of 5 20% Name First Last Daytime telephone number*Date of birth* Date Format: DD slash MM slash YYYY Sex*MaleFemaleAddress* Your medical informationCurrent Health Problems*Medical History of note? Or currently undergoing chemotherapy/radiotherapy/ transplant ?*Current Medication*Allergies (e.g. food, latex, medication)*Have you ever had a serious reaction to a vaccine given to you before?*YesNo Women onlyAre you pregnant?YesNoNumber of weeksAre you breastfeedingYesNoAre you planning a pregnancy whilst away?YesNo Travel detailsDeparture date* Date Format: DD slash MM slash YYYY Total length of tripDestination 1Length of stay at destination 1Destination 2Length of stay at destination 2Destination 3Length of stay at destination 3Destination 4Length of stay at destination 4Type of trip Holiday Business Volunteer Work Healthcare Worker Staying in a hotel Cruise ship trip Visiting friends/family Safari Pilgrimage Medical tourism Backpacking Camping/hostels Organised adventure Diving Please tick all that apply VaccinationsVaccination History: Have you ever had any of the following vaccinations / malaria tablets and if so when?Tetanus Date Format: DD slash MM slash YYYY Polio Date Format: DD slash MM slash YYYY Cholera Date Format: DD slash MM slash YYYY Diphtheria Date Format: DD slash MM slash YYYY Typhoid Date Format: DD slash MM slash YYYY Meningitis Date Format: DD slash MM slash YYYY Yellow fever Date Format: DD slash MM slash YYYY Influenza Date Format: DD slash MM slash YYYY Rabies Date Format: DD slash MM slash YYYY Hepatitis A Date Format: DD slash MM slash YYYY Hepatitis B Date Format: DD slash MM slash YYYY Japanese encephalitis Date Format: DD slash MM slash YYYY Tick borne encephalitis Date Format: DD slash MM slash YYYY BCG Date Format: DD slash MM slash YYYY Pneumococcal Date Format: DD slash MM slash YYYY Malaria tabletsOther vaccinationsAdditional informationPLEASE NOTE: Some Vaccines/Malaria Tablets are not covered by the NHS and will incur a charge; this will be discussed before the vaccines are given. There may be a charge for private patients.Consent* I agree to the privacy policy.By submitting your details you are consenting to providing this information for improving our services to you. The data you supply on this form will be securely stored on our website, which is hosted by a third party. We will retain this information on the website for no longer than 7 calendar days. your contact details will not be sold or shared with a third party. I understand I can revoke this consent at anytime by contacting the practice. Our privacy policy can be viewed on this website.
