+44(0)1225 863 278


Travel Clinic

Travel Questionnaire

Name:  Sex: 
Date of Birth: 
Address: 
Daytime Tel: 
Email: 
Trip Details
Departure:  Duration: 
Itinerary
Country Duration Availability of Medical Help
(If you will be travelling to a place where medical help is not readily on hand, estimate how long it would take to reach a doctor)
Trip Description - Please select appropriate options
Purpose of Trip:  Type of Trip: 
Accommodation:  Travelling
Location Type:  Activity Type: 
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 medication (including oral contraception)
Have you recently suffered from any infection (eg. 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, chemotheropy 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?
Further information: 
Vaccination History
Tetanus:  Date: 
Diphtheria:  Date: 
Hepatitis A:  Date: 
Meningitis:  Date: 
Influenza:  Date: 
Jap B Enceph:  Date: 
Maleria Tablets:  Date: 
Polio:  Date: 
Typhoid:  Date: 
Hepatitis B:  Date: 
Yellow Fever:  Date: 
Rabies:  Date: 
Tick Borne:  Date: 
Vaccination Other: 

 

Bradford-on-Avon Occupational Health Services
St. Margarets Surgery, 29 Bridge Street, Bradford on Avon, Wiltshire, BA15 1BY, UK
Tel: +44(0)1225 863 278  •  Fax: +44(0)1225 868 493 • Email: This email address is being protected from spambots. You need JavaScript enabled to view it.