East Norwich Medical Partnership
Travel Enquiry Questionnaire
Full Name: / Date of BirthMale/Female* / Contact Telephone Number:
*Please delete as necessary
Travel Details
Countries & Areas VisitingDeparture Date
Length of Stay
Away from Medical help
If so how remote?
Please tick below as appropriate to best describe the trip:
Type of Trip / Business / Pleasure / OtherHoliday Type / Package / Self-Organised / Backpacking
Camping / Cruise Ship / Trekking
Accommodation / Hotel / Relative/Family Home / Other
Travelling / Alone / With Family/Friend / In a Group
Staying in area which is / Urban / Rural / Altitude
Planned Activities / Safari / Adventure / Other
Personal Medical History
Do you have any recent or past medical history of note (including diabetes, heart or lung conditions / Yes/No*List any current or repeat medications:
Do you have any allergies for example eggs, antibiotics, nuts? / Yes/No*
Have you ever had a serious reaction to a vaccine given before? / Yes/No*
Does having an injection make you 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*
Women Only: Are you pregnant or planning pregnancy or breast feeding? / Yes/No*
Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this? / Yes/No*
Please include any further information which may be relevant.
*Please delete as necessary
Vaccination History
Have you ever had any of the following Vaccinations/Malaria Tablets, and if so when?
Tetanus / Polio / Diphtheria / Malaria TabletsTyphoid / Hepatitis A / Hepatitis A / Tick Borne
Meningitis / Yellow Fever / Influenza / Jap B Enceph
Rabies / Other:
Patient Signature: Date:
Full Name: / Date of BirthMale/Female* / Contact Telephone Number:
Appointment Information
Nurse:Appointment Length Required:
Appointment Date / Week Commencing:
Reception:
Date & Time of Appointment
Receptionist Name
Travel vaccines recommended for this trip:
Disease Projection / Required / Further InformationHepatitis A / Yes / No*
Hepatitis B / Yes / No*
Typhoid / Yes / No*
Cholera / Yes / No*
Tetanus / Yes / No*
Diphtheria / Yes / No*
Polio / Yes / No*
Meningitis / Yes / No*
Yellow Fever / Yes / No*
Rabies / Yes / No*
Japanese B Encephalitis / Yes / No*
Other
*Please delete as necessary
Travel Leaflets
Travel Record Card / Yes / No* / Travax Sheet / Yes / No**Please delete as necessary
Malaria Prevention Advice and Malaria Chemoprophylaxis
Chloroquine and Proguanil / Atovaquone and Proguanil (Malarone)Chloroquine / Mefloquine
Doxycycline / Malaria Advice Leaflet
Nurse Preparing Information
Nurse Giving Vaccinations
Patient Statement
- I have no reason to think I may be pregnant.
- I have received information on the risks and benefits of the vaccines recommended, and have had the opportunity to ask questions.
- I consent to the vaccines being given.
Signature: Date: