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Microsoft word - travel clinic questionnaire - feb 2014.rtf

HAY-ON-WYE & TALGARTH MEDICAL PRACTICE
TRAVEL HEALTH QUESTIONNAIRE
Please complete this questionnaire and return it to the Medical Centre at least three
weeks prior to your Clinic Appointment
TRAVEL IMMUNISATIONS SHOULD BE GIVEN AT LEAST 4 WEEKS BEFORE TRAVEL

NAME: ………………………………………………………

DOB …………….

ADDRESS: …………………………………………………………………….
………………………………………………………………………………………………
TELEPHONE NUMBER: …………………………………………………………….
1. Departure date: ____________________ 2. Length of stay: _____________
3. Direct flight : YES/NO
4. Which countries do you

intend to visit and the
duration in each?
Please also state region of

Please bring any additional paperwork e.g. recommended by travel agents/previous travel
vaccination records

5. Will your journey take you to the: 6. Will you be staying in:

Hotels __
Relatives’
Islands __
Accommodation
7. Are you travelling with:

Partner __

8. Are you going on:

An organized package tour
Organising it yourself
Taking a backpacking holiday

9. Is your holiday for:

Pleasure
Business
A period of voluntary service (in a remote area) __

10. Will you be on safari? YES/NO
If yes please give details: _______________________________________

11. Will you be in areas where medical help is non-existent (even for a short
period)? YES/NO
If yes please give details: _______________________________________
12. Are you suffering from any minor ailments? YES/NO
If yes please give details: _______________________________________
13. Do you have any long term medical conditions? YES/NO
If yes please give details: _______________________________________
14. Do you have a history of epilepsy? YES/NO
If yes please give details: _______________________________________
15. Do you have any history of depression? YES/NO
If yes please give details: _______________________________________
16. Have you ever had your spleen removed: YES/NO
17. Have you ever suffered a bad reaction to any type of vaccine? YES/NO
If yes please give details: _______________________________________
18. Do you have any allergies e.g. eggs? YES/NO
If yes please give details: _______________________________________
19. Are you currently on any medication including the oral contraceptive pill?
YES/NO
If yes pleases give details_______________________________________
20. Are you pregnant, breast feeding or planning a pregnancy? YES/NO
If yes please give details: _______________________________________
22. Have you previously had any vaccinations? YES/NO
If yes please give details:

PREVIOUS VACCINES

Please note that there are some vaccines required for travel in certain countries
which are not provided by the NHS, therefore patients will be charged for these
vaccines
DECLARATION BY PATIENT:
I agree that the information I have supplied is correct
Signed: ……………………………………………………. Date: ……………………


Patient Name: _________________________________ DOB: _____________
Patient Number: _______________________
Recommended Date of First Appointment: ____________________________

Vaccine Recommended:

Hepatitis

* Not given at the Medical Centre – if required, you will be re-directed to an appropriate
facility
Malaria:
Chloroquine

Record of Other Advice:

Health advice for travelers leaflet YES/NO

COMMENTS/NOTES:

GP :

Nurse : ……………………………………………………….
Date :
……….……………………………………………….

Source: http://www.hay-garth.co.uk/pdf/questionnaire.pdf

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