Travel Health Questionnaire
Surname…………………………… Forename…………………………………
Date of Birth……………………… GP………………………………………..
1. Please list the countries to be visited, including any stop-overs?
(stop-overs should include short stays in airports)
DATE OF DEPARTURE |
COUNTRY |
CITIES |
RURAL REGION |
THE COAST |
LENGTH OF STAY |
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(please tick those areas of a country to be visited)
2. Will you be travelling to your destination by:
a) Aeroplane b) Boat c)Car d)Train e)Bus
Other-please give details…………………………………………………….
3. Where do you intend to stay while abroad?
(eg first class or budget hotels, guest houses, camping or with friends or relatives)
………………………………………………………………………………….
………………………………………………………………………………….
4. What is the purpose of your travel?
a) Holiday b)Visiting friends or relatives
c) Work – please specify……………………………………………………….
………………………………………………………………………………….
d) Other – please give details …………………………………………………..
………………………………………………………………………………….
5. Have you had any of the following?
(please tick those that apply)
Heart Problems Splenectomy Allergies
Diabetes Chemotherapy Asthma
Please give details of any other medical problems……………………………..
………………………………………………………………………………….
………………………………………………………………………………….
6.Are you pregnant? No Yes
7.Do you take any tablets? No
Yes (please list any medication, including any bought over the counter from the Chemist ,
you are currently taking)
……………………………………………………………………………………
……………………………………………………………………………………
8. Have you had any holiday/travel vaccinations before?
No Yes (please list)
……………………………………………………………………………………
…………………………………………………………………………………
THANK YOU FOR COMPLETING THIS FORM.
**REMEMBER TO BRING IT WITH YOU TO YOUR APPOINTMENT WITH THE NURSE**
PATIENT CONSENT
I have received and understood the advice given to me concerning:-
Signed…………………………………………………….Date………………