Travel Questionnaire

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Personal Details

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.

We will place this form on your record. Please then book an appointment with nurse (only) and advise reception that you have completed this form and they can review it prior to your appointment. The form will be be reviewed in conjunction with a due travel appointment with nurse only. Please note there are limted travel vaccine clinic appointments and it will be quicker to book with other providers as per Travel Clinic (westhampsteadmedicalcentre.com).

Please double check you've entered the correct email address

Gender: *

May be used to identify you

Dates and Trip Details

Holiday Type: *

Type of Trip: *

Accommodation: *

Travelling: *

Staying in area which is: *

Planned Activities: *

Personal Medical History

Including diabetes, heart or lung conditions

Have you ever had a serious reaction to a vaccine given to you before?:

Does having an injection make you feel faint?:

Do you or any close family members have epilepsy?:

Do you have any history or mental illness including depression or anxiety?:

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?:

Have you taken out travel insurance and if you have a medical condition, informed the insurance company about this?:

Have you ever had any of the following vaccinations / malaria tablets?:

Signed & Dated

Type your full name to sign this form

This form is automatically dated upon submission.

Privacy Consent

This form collects personal and medical information about you. We use this information to allow the practice team to contact you. Please read our Privacy Policy to discover how we protect and manage your submitted data.

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