Travel Questionnaire If you are travelling abroad please make sure you contact us 6 – 12 weeks to arrange any vaccinations that may be necessary. To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment. Name First Last Date of Birth Day Month Year Contact NumberEmail Details about your tripDate of Departure Day Month Year Trip durationPlease give details of country to be visited, length of stay and how remote you will be from medical helpDescription of your tripPurpose of your trip Business Pleasure Other Please specifyType of Trip Package Self-Organised Backpacking Camping Cruise Ship Trekking Accommodation Hotel Friends/Family Other Please specifyTravelling Alone With Friends/Family In a Group Location Type Urban Rural Altitude Activity type Safari Adventure Other Please specifyPersonal Medical HistoryList all chronic medical conditions that you have (e.g. diabetes, heart or lung conditions, etc.)List all allergies that you have (e.g. eggs, nuts, antibiotics, etc.)If you have had a serious reaction to a vaccine in the past, which vaccine was it?List all of your current medications (including oral contraception)Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)? Yes No Does having an injection cause you to feel faint? Yes No Do you or any close family members have epilepsy? Yes No Do you have any history of mental illness including depression or anxiety? Yes No Have you recently undergone radiotherapy, chemotherapy or steroid treatment? Yes No Have you taken out travel insurance? Yes No If you have a medical condition, have you told your insurance company about it? Yes No Are you pregnant, planning pregnancy or breast feeding? Yes No N/A Write below any further information that might be relevant. OptionalVaccination HistoryHave you ever had any of the following vaccinations / tablets and if so, when? Tetanus Optional Polio Optional Diphtheria Optional Typhoid Optional Hepatitis A Optional Hepatitis B Optional Meningitis Optional Yellow Fever Optional Influenza Optional Rabies Optional Japanese B Enceph Optional Tick Borne Optional Malaria Optional This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the nhs. Please read our privacy policy to discover how we protect and manage your submitted data. I consent to the practice collecting and storing my data from this form.