TRAVEL HEALTH QUESTIONAIRE
PRIVATE & CONFIDENTIAL
bullet Please complete this form and return it to the practice nurse ASAP before your first appointment for travel health advice.
bullet Where possible, make an appointment at least 8 weeks before your departure.
bullet A form should be completed for each person that will be travelling.
DATE FORM SUBMITTED BY PATIENT: ……………………
 

Name:

Will you be staying in hotels or under more primitive conditions (e.g. camping)?

Address:

 

 

Do you plan any safaris, jungle exploration or travel in different terrain?

Departure Date?

Duration of stay abroad?

Are you allergic to anything?

Telephone Number:

Are you taking any medications:
Please list below:

Date of Birth:

Name of GP:

1. Which countries, in sequence, do you intend to
visit? (Include any stopovers, however brief, and
please be specific about the areas you are visiting).

Remember: If you are receiving medication, make sure that you take enough supplies to last through your overseas visit.

Are you pregnant or breastfeeding? Yes/No

Are you immunosuppressed?

Have you any serious or chronics illness?

Are you receiving any radiotherapy or chemotherapy or steroid treatment?

2. Written notes checked?

Yes / No

3. Computer notes checked?

Yes / No

 

Vaccination

Date Previously Given
Required for travel
Date Given
Tetanus
     
Polio
     
D/T Combined
     
Diptheria
     
Hepatitis A
     
Hepatitis B
     
Typhoid
     
Men C
     
Rabies
     
Yellow Fever