Travel Questionnaire

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. Please be aware that we require at least 6 weeks notice before you travel to allow time for your vaccinations.

Contact Number

Details about your trip

Trip duration

Please give details of country to be visited, length of stay and how remote you will be from medical help

Description of your trip

Please specify

Personal Medical History

List all chronic medical conditions that you have (eg. diabetes, heart or lung conditions) Optional

List all allergies that you have (eg. eggs, nuts, antibiotics) Optional

If you have had a serious reaction to a vaccine in the past, which vaccine was it? Optional

List all of your current medications (including oral contraception) Optional

Write below any further information that might be relevant. Optional

Details about your trip

Description of your trip

Personal Medical History

Vaccination History

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