Travel Health Questionnaire - Wargrave House Surgery

Please complete the form below to get more information about what travel immunisations you require.

Most vaccines are given at least 2 weeks before travel, and some more complicated regimes take longer. Please try to give us prior notice (preferably 6 weeks).

Tittle *

Full Name *

Date of Birth *

Address *

Address

Zip/Postal

City

Country

Email *

Is there any possibility you may be pregnant? *

Yes

No

Destination(s)

UK Departure Date *

Total duration of trip (in days) *

1st Country being visited (specify areas if long haul) *

Length of stay (include stopover destinations)

2nd Country being visited (specify areas if long haul)

Length of Stay

3rd Country being visited (specify areas if long haul)

Length of Stay

Further Information

Type of travel and purpose of trip- Please tick all that apply *

Are you fit for travel? *

Yes

No

Do you have any allergies? *

Yes

No

State Allergies

Other Information you should disclose *

Travel Questionnaire