Download The Yellow Practice Drumhar Health Centre

Eden Villa Practice
Travel Health Questionnaire
Date form received:
Personal details
Name:
Date of birth:
Easiest contact telephone number:
Dates of trip
Date of Departure
Return date or overall length of trip
Itinerary and purpose of visit
State country and exact location
to be visited (full itinerary will be
helpful)
Length of stay
Hours away from medical attention
1.
2.
3.
4.
Please tick as appropriate below to best describe your trip:
1. Type of trip
Business
Pleasure
Other
2. Holiday type
Package
Self organised
Backpacking
Camping
Cruise ship
Trekking
3. Accommodation
Hotel
Other
4. Travelling
Alone
5. Staying in an area
which is
Urban
Relatives / family
home
With family /
friend
Rural
6. Planned activities
Safari
Adventure
Other
In a group
Altitude
Please turn over…..
Eden Villa Practice
Travel Health Questionnaire
Medical History
Do you have any recent or past medical history of note? (Including diabetes, heart or lung
conditions)
List any current or repeat medications
Do you have any allergies for example to eggs, antibiotics, nuts?
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?
Please write below any further information which may be relevant
Details of any known vaccinations not given by GP, i.e. independent travel clinic (vaccination,
date, place)
Vaccinations
Are there any vaccinations you DO NOT wish to have? Please detail in the space below.
If you require any of travel vaccination, a prescription will be issued for you unless you state
otherwise below.
Details of costs can be found in the ‘Travel Information Booklet’.
For discussion when risk assessment is performed within your appointment:
I have no reason to think that I might be pregnant. I have received information on the risks and
benefits of the vaccines recommended and have had the opportunity to ask questions. I consent to
the vaccines being given.
Signed __________________________________________ Date ___________________
WE ASK THAT YOU PLEASE GIVE US AT LEAST 8 WEEKS NOTICE PRIOR TO TRAVEL