138 Chapel Street, Salford M3 6AF England    0161 819 4790

138 Chapel Street, Salford M3 6AF England   
0161 819 4790



Travel Questionnaire


Please complete the form below and then arrange for an appointment with one of our practice nurses. We recommend that this is done at least 8 weeks before you leave for your holiday. Our Travel Advice page is filled with useful information if you are planning to travel outside of the UK. This service for registered patients only.

Fields marked with an asterisk are compulsory.


1

Personal Information:

2

Trip Dates:

3

Itinerary:

4

Trip Description – please tick all appropriate boxes:

Purpose of Trip


Type of Trip





Accomodation


Travelling


Location Type


Activity Type

5

Personal Medical History:

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

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

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

List all of your current medications (including oral contraception)

Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)?

Does having an injection cause you to feel faint?

Do you or any close family members have epilepsy?

Do you have any history of mental illness including depression or anxiety?

Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

Have you taken out travel insurance?

If you have a medical condition, have you told your insurance company about it?

Are you pregnant, planning pregnancy or breast feeding?

6

Vaccination History:

Have you ever had any of the following vaccinations / tablets and if so, when?




Translate ยป