Travel Health Questionnaire

Name
First Last
Daytime telephone number*
Date of birth*
Date Format: DD slash MM slash YYYY
Sex*
- Male
- Female
Address*

Your medical information
Current 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?*
- Yes
- No

Vaccinations
Vaccination 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 tablets
Other vaccinations
Additional information
PLEASE 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.

Step 1 of 5

Your medical information

Women only

Travel details

Vaccinations