HomeTravel Questionnaire Travel Questionnaire To help us offer the appropriate advice, please fill out the online form before coming to see the nurse.
Personal Details Name* Address* Postcode* Date of Birth* Sex FemaleMale Mobile Number Email Address Trip Dates Departure Duration Itinerary Country Duration Availability of Medical Help Country Duration Availability of Medical Help Country Duration Availability of Medical Help Country Duration Availability of Medical Help Country Duration Availability of Medical Help Trip Description - please tick all appropriate boxes: Purpose of Trip: BusinessPleasureOther Type of Trip: PackageSelf-OrganisedBackpackingCampingCruise ShipTrekking Accommodation: HotelOtherFriends/Family Travelling: AloneIn a GroupWith Friends/Family Location Type: UrbanRuralAltitude Activity Type: SafariAdventureOther Personal Medical History List all chronic medical conditions that you have (eg. diabetes, heart or lung conditions) List all allergies that you have (eg. eggs, nuts, antibiotics) 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 Does having an injection cause you to feel faint? Yes Do you or any close family members have epilepsy? Yes Do you have any history of mental illness including depression or anxiety? Yes Have you recently undergone radiotherapy, chemotherapy or steroid treatment? Yes Have you taken out travel insurance? Yes If you have a medical condition, have you told your insurance company about it? Yes Are you pregnant, planning pregnancy or breast feeding? Yes Write below any further information that might be relevant: Vaccination History Have you ever had any of the following vaccinations / tablets and if so, when? Tetanus Yes Date Polio Yes Date Diphtheria Yes Date Typhoid Yes Date Hepatitis A Yes Date Hepatitis B Yes Date Meningitis Yes Date Yellow Fever Yes Date Influenza Yes Date Rabies Yes Date Jap B Enceph Yes Date Tick Borne Yes Date Malaria Tablets Yes Date Other Send
