Travel Health

Pre-Travel Questionnaire

The information on this form will help your nurse to find out if you may need any vaccinations before you travel to help keep you healthy on your trip. This form should be given to you nurse when you visit the surgery. Please complete all details about your planned trip.

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Please give details of the resort/region as well as the country. Remember to list countries you will be travelling through as well as those you will be staying in.

Medical History

Please give any conditions that may affect your travel plans e.g. pregnancy, diabetes, heart, thymus or spleen problems, HIV/Aids or allergies.
I have received travel information and advice on the risk and benefits of the vaccines recommended and have had the opportunity to ask questions.

I consent to the vaccines being given.

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Before you travel