Travel Health - Dr I.M. Raja & Partner

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.

Name

First Last

Date of departure:

Date of Birth:

Date of Return:

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.

I will be visiting the following countries

Time in Country (days)

Purpose of trip e.g. holidays/visiting relatives. Include any at risk activities planned

Type of accommodation e.g hotel/hostel/campsite/boat

Do you plan to travel abroad again in the future?

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.

Allergies: (e.g. eggs antibiotics)

Women only: Are you pregnant or planning pregnancy or breastfeeding? Optional

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.

Patient Signature:

Date:

Print Name:

Nurse Signature: Optional

Date: Optional

Print Name: Optional

Before you travel

Make sure you get adequate travel insurance for all the activities you’re planning on taking part in. Optional

Pack a first aid kit, including a sterile kit of emergency equipment if you are going somewhere remote. Optional

Make sure that you have adequate supplies of your prescription medication. Check with the airport and airline for any restrictions they may have on travelling with medicines or administrative devices. Optional

Have you had a recent dental and medical check-up? Optional

Find out more about the region you are travelling to by visiting The Foreign Office website and for advice on specific countries [www.fco.gov.uk] Optional