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Travel Questionnaire

Please complete the form below if you are travelling abroad. If you would prefer you can print out a form from here and post it to us or drop it in at the surgery.

Travel Questionaire

Please complete at least 4-6 weeks before travel.
  • It is your responsibility to phone the surgery approximately 1 week after completing the questionaire to confirm vaccines required and make appointment.

  • Country to be visitedArea/RegionLength of stayTravelling to remote area/away from medical help? 
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  • Please select as appropriate below to best describe your trip

  • Personal medical history

  • Add a new row
  • Vaccination History

    NB - There will be a charge for anti-malarials as they are not available on the NHS and there is a fee payable for some vaccines e.g. yellow fever.
  • TypeWhen you had it 
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    Please state the type and when you had them.