Travel Questionnaire If you are travelling abroad please make sure you contact us in plenty of time to arrange any vaccinations that may be necessary. To help the Travel Nurses assess your travel needs it is important that they are in receipt of the assessment form before your appointment. Please be aware that we require at least 6 weeks notice before you travel to allow time for your vaccinations. Name First Last Date of Birth Day Month Year Contact NumberEmail Enter Email Confirm Email Gender Female Male Details about your tripDate of Departure Day Month Year Trip duration Please give details of country to be visited, length of stay and how remote you will be from medical helpDescription of your tripPurpose of your trip Business Optional Pleasure Optional Other Optional Are you going to be carrying out volunteer work as part of your holiday? Personal Medical HistoryHave you received any travel vaccines privately that are not currently on your GP records?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?This form collects your name, date of birth, email, other personal information and medical details. This is to confirm you are registered with the practice, to allow the practice team to contact you and also to update your medical records held by the practice and our partners in the nhs. Please read our privacy policy to discover how we protect and manage your submitted data. I consent to the practice collecting and storing my data from this form. Optional
