TRAVEL HEALTH QUESTIONNAIRE
Please hand the completed form in at reception and then phone us 1 week later to find out which, if any vaccinations you will need and to arrange an appointment if needed.
A form should be completed for each person travelling.
Name………………………………….. D.O.B. …………………...
Address………………………………………………………………….
Tel no…….…………………………
Please list all the countries to be visited, including stopovers?
(stop-overs should include short stays in airport terminals)
Date of departure / Country / Cities Rural Coast(Tick areas to be visited) / Length of stay
How will you be travelling to your destination? (Please tick all those that apply)
Aeroplane Boat Car train Bus
Other – Please give details………………………………………………….
What type of transport do you expect to use while abroad?
(eg. Local buses, car hire, renting mopeds or bicycles)
………………………………………………………………………………….
Where do you intend to stay while abroad?
(eg. international or budget hotels, guesthouses, camping or with relatives)
………………………………………………………………………………….
What is the purpose of your travel? (Please tick those that apply)
Holiday Visiting relatives/friends
Work – What type of work?………………………………………………….
Other – Please give details: ……………………………………………
Are you planning/anticipating any sporting activities?
No Yes
(Please list)………………………………………………………………………
Have you had any of the following? (Please tick those that apply).
Heart problems Splenectomy Allergies High blood pressure
Chest problems Diabetes Asthma Back problems
Please give details of any other medical problems………………………………..
……………………………………………………………………………………
Have you recently had any illness, surgery or dental treatment?
No Yes (Please give details)………………………………………….
……………………………………………………………………………………
Are you pregnant? Yes No
Do you take any tablets or medicines? No Yes
(Please give details)…………………………………………….……………….
Do you smoke? Yes No Drink alcohol? Yes No
Please tick the following vaccinations that you have been given and the dates you had them. Dates can be approximated if you cannot remember exactly.
Vaccination / Tick / Date / Vaccination / Tick / DatePolio / Hepatitis A
Tetanus / Hepatitis B
Diphtheria / Typhoid
BCG / Yellow Fever