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. Name First Last Date of Birth DD MM YYYY GenderMaleFemaleEmail Address Easiest contact telephone number:It is your responsibility to phone the surgery approximately 1 week after completing the questionaire to confirm vaccines required and make appointment.Date of Departure Return Date ItineraryCountry to be visitedArea/RegionLength of stayTravelling to remote area/away from medical help? Please select as appropriate below to best describe your tripType of Trip Business Pleasure Other Holiday Type Package Self organised Backpacking Camping Cruise Ship Trekking Accommodation Hotel Relative/family Other Travelling Alone With family/friend In a group Staying in area which is: Urban Rural Altitude Planned Activities Safari Adventure Other Personal medical historyDo you have any recent or past medical history of note? (including diabetes, heart or lung conditions)YesNoList any current or repeat medications Do you have any allergies for example to eggs, antibiotics, nuts?YesNoHave you ever had a serious reaction to a vaccine given to you before?YesNoDoes having an injection make you feel faint?YesNoDo you or any close family members have epilepsy?YesNoDo you have a history of mental illness including depression or anxiety?YesNoHave you recently undergone radiotherapy, chemotherapy or steroid treatment?YesNoWomen only: Are you pregnant or planning pregnancy or breast feeding?YesNoVaccination HistoryNB - 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.Have you ever had vaccinations/malaria tablets such as: Tetanus, Polio, Diptheria, Typhoid, Hepatitis A, Hepatitis B, Meningitis, Yellow Fever, Influenza, Rabies, Jap B Enceph, Tick Borne.TypeWhen you had it Please state the type and when you had them.I confirm the above answers to be correct to the best of my knowledge and request immunisation for my trip together with advice on anti-malarials if appropriate.*Select here to confirm This iframe contains the logic required to handle Ajax powered Gravity Forms.