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Travel questionnaire
Home
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Travel clinic
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Travel questionnaire
Travel questionnaire
Fields marked with an asterisk (*) are required.
First name
*
Surname
*
Email address
*
Date of birth
*
Home telephone
*
Mobile telephone
*
Work telephone
Address
*
York / Hull
*
Select
York
Hull
Do you consent to a message being left on your home or mobile phone?
*
Yes
No
Do you consent to the practice using the above details to update your medical records?
*
Yes
No
Date of departure
*
Return date/overall length of trip
*
Countries to be visited (please include region information)
Type of trip
*
Business
Pleasure
Other
Holiday type
*
Package
Self Organised
Back Packing
Camping
Cruise
Trekking
Accommodation
*
Hotel
Family Home
Other
Travelling
*
Alone
With family/friends
In a Group
Staying in an area which is
*
Urban
Rural
Altitude
Planned Activities
List any medications you currently or often take – include alternative therapies i.e. St Johns Wort
Do you have any allergies to medications or foods?
Have you had a serious reaction to a vaccination before?
Have you recently undergone chemotherapy, radiotherapy or steroid treatment?
(Women only) Are you pregnant/planning a pregnancy or breast feeding?
(Women only) Are you taking oral contraception – the Pill / Mini Pill? If so which one?
Any other information?
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