Travel questionnaire Please complete this form as fully as possible before attending your travel appointment. 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: MM slash DD 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 Vaccination History: Have you ever had any of the following vaccinations / malaria tablets and if so when?Tetanus Date Format: MM slash DD slash YYYY Polio Date Format: MM slash DD slash YYYY Cholera Date Format: MM slash DD slash YYYY Diphtheria Date Format: MM slash DD slash YYYY Typhoid Date Format: MM slash DD slash YYYY Typhoid Date Format: MM slash DD slash YYYY Meningitis Date Format: MM slash DD slash YYYY Yellow fever Date Format: MM slash DD slash YYYY Influenza Date Format: MM slash DD slash YYYY Influenza Date Format: MM slash DD slash YYYY Rabies Date Format: MM slash DD slash YYYY Rabies Date Format: MM slash DD slash YYYY Hepatitis A Date Format: MM slash DD slash YYYY Hepatitis B Date Format: MM slash DD slash YYYY Japanese encephalitis Date Format: MM slash DD slash YYYY Tick borne encephalitis Date Format: MM slash DD slash YYYY BCG Date Format: MM slash DD slash YYYY Pneumococcal Date Format: MM slash DD slash YYYY Malaria tabletsOther vaccinationsAny additional 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.
