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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