Travel Health Questionnaire
Please complete a form for each member of your party.
Please return the completed questionnaire at least 4 weeks prior to you date of departure where possible.
Personal details
Name: Title:
Date of Birth: Male / Female
Nationality:
Home address:
Postcode: GP Practice:
Home telephone number: Email:
Mobile phone number:
Please supply Information about your trip in the sections below
Date of Departure: / Complete Length of Trip:Country to be visited (Please include any airport stops) / Exact location/region / City or Rural / Length of Stay
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Details of Trip- Please tick all that apply
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o Holiday
o Backpacking
o Business Trip
o Expatriate
o Visiting Friends and Family
o Volunteer Work
o Pilgrimage
o Medical Tourism
o School Trip
o Offshore Work
o Medical Elective
o Staying in Good Standard Hotel
o Staying in Budget accommodation
o Cruise Ship
o Camping/Hostels
o Adventure
o Altitude
o Safari
o Diving
o Other- Please specify
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Is there any additional information you think we should know about your trip?
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Please supply details of your Medical History
Yes / No / DetailsProblems with your immune system – any immunological therapies
Are you or have you been taking steroids in the last 3 months
Recent chemotherapy/radiotherapy
Liver Disease
Kidney Disease (other than an infection)
Epilepsy/Seizures including family history in first degree relative
Depression/Anxiety requiring treatment
Family history in first degree relative of severe mental health disorder
Skin Complaints
Any surgical operations in the past including removal of spleen/thymus gland/ organ transplant
Any other medical condition not listed above ( past/current)
Are you allergic to medications or foods (in particular eggs/chicken)
Have you ever had a severe reaction to a vaccine or Mantoux (TB) testing in the past
Are you pregnant?
Are you breast-feeding?
Are you planning pregnancy within 3 months of travel?
Are you currently taking any regular medication? Yes/No
Please list:
PREVIOUS VACCINATION HISTORY (Please complete the table below ensuring you insert the date the vaccine was received)
PLEASE BRING A COPY OF YOUR VACCINATION HISTORY BOOKLET/CERTIFICATE TO YOUR APPOINTMENT. Please note we are unable to access your GP records.
TetanusDate- / Yellow Fever
Date- / Jap B Encephalitis
Dose 1 Date-
Dose 2 Date-
Dose 3 Date-
Booster Date-
Please indicate if you received Green Cross or IXIARO vaccine
Polio
Date- / Mantoux Test
Date-
BCG-
Date-
Diphtheria
Date- / Meningitis
Date-
Typhoid
Date- / Influenza
Date-
Hepatitis A
Dose 1 Date-
Dose 2 Date-
Booster Date- / MMR
Dose 1 Date-
Dose 2 Date- / Cholera
Dose 1 Date-
Dose 2 Date-
Booster Date-
Hepatitis B
Dose 1 Date-
Dose 2 Date-
Dose 3 Date-
Booster Date- / Rabies
Dose 1 Date-
Dose 2 Date-
Dose 3 Date-
Booster Date- / Tick Borne Encephalitis
Dose 1 Date-
Dose 2 Date-
Dose 3 Date-
Booster Date-
Please indicate your availability for appointment by marking an X in the appropriate box or boxes below:
AM / PMMonday / DETAIL CLINIC AVAILABILITY HERE
Tuesday
Wednesday
Thursday
Friday
Saturday (occasional)
PLEASE RETURN COMPLETED FORMS TO:
A MEMBER OF THE ADMINISTRATION TEAM WILL EITHER EMAIL OR CALL YOU TO ARRANGE A CONVENIENT APPOINTMENT.
YOUR GP SURGERY MAY BE ABLE TO PROVIDE SOME VACCINES FREE OF CHARGE, PLEASE CONTACT THEM FOR MORE INFO PRIOR TO RETURNING YOUR FORM.
THERE ARE SOME USEFUL WEBSITES BELOW THAT YOU MAY WISH TO LOOK AT FOR
INFORMATION PRIOR TO YOUR APPOINTMENT:
www.fitfortravel.nhs.uk www.malariahotspots.co.uk www.areyouready2go.co.uk
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