Travel Questionnaire

If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary. To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment. Please be aware that we require at least 6 weeks notice before you travel to allow time for your vaccinations.

Last Updated: 23/02/2021

  • Your Details

    Date of Birth
    For example, 15 3 1984

  • Trip Details

    Departure Date
    For example, 15 3 1984

  • Trip Description

    Purpose of Trip
    Type of Trip
    Accommodation
    Travelling
    Location Type
    Activity type

  • Personal Medical History

    Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
    Have you taken out travel insurance?
    If you have a medical condition, have you told your insurance company about it?
    Are you pregnant, planning pregnancy or breast feeding?

  • Vaccination History

    Have you ever had any of the following vaccinations / tablets and if so, when?
    THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA.
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