Tower House Surgery

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Practice Information

Travel Questionnaire

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To be filled in, by or on behalf of the person travelling abroad, at least 8 weeks (ideally 12 weeks) prior to departure.
This will enable the Practice Nurse to give advice on precautions and immunisations required for a safe trip.

Patient Details
Patient First Name
Patient Last Name
Current Patient Address
Patient Date of birth
Telephone No

Travel Details
Date of departure
Date of return
Destinations, including excursions
Reason for travel (eg holiday, business, visiting friends)
Mode of travel
Accommodation whilst abroad
Types of activities to be undertaken

Health Details Have you any of the following medical conditions?
Heart problems
Splenectomy
Epilepsy
Breathing problems
Diabetes
Asthma
Skin conditions
Any other medical conditions?
Have you any allergies?
Have you ever had an adverse reaction to a vaccine?
Have you recently had surgery?
Please list current medications
Contraception
Are you pregnant/breast-feeding or planning to become pregnant?
Do you smoke?
Do you drink alcohol?

Vaccination Details Have you had any of the following vaccinations? Or other vaccinations? If yes, please select vaccinations and dates, if known:
POLIO
TETANUS
DIPTHERIA
BCG
TYPHOID
HEPATITIS A
MENINGITIS A & C
RABIES
YELLOW FEVER
JAPANESE BENCEPHALITIS
TICK-BORNEENCEPHALITIS
HEPATITIS B
Are there any members of your household who have not had their full course of POLIO immunisation?

Travel Questionnaire