Travel questionnaire

TRAVEL QUESTIONNAIRE
Please bring the completed questionnaire to the surgery prior to your appointment for vaccinations. If you are unable to answer any questions please discuss these with the practice nurse at your appointment.
NAME……………………………………………………………… DATE OF BIRTH……………………
ADDRESS………………………………………………………………………………………………………
1. In order of visit, which Countries and Resorts are to be visited. Please give as much detail as possible
and if more space is needed, please bring a copy of your itinerary.
…………………………………………………………. length of stay………………………………….
…………………………………………………………. length of stay………………………………….
…………………………………………………………. length of stay………………………………….
…………………………………………………………. length of stay………………………………….
2. What type of holiday: eg. diving / mountain climbing / back packing / other

3. What accommodation will you be staying in? hotel / villa / apartment / camping

4. Will you be going “off the beaten track”? Yes / No

5. When do you plan to go? Date ………………………………………………….
6. How long will you be away? ……………………………………………………….
7. Please indicate and give dates if you have had any of the following vaccinations / medications:
Typhoid…………………….…. Yellow Fever……………….….… Cholera…………….……
Japanese Encephalitis……………………………. Hepatitis B……………………….……….
Low Dose Diph/Tet………………………………. Meningitis………….………………………
Polio…………………………………… Tick Borne Encephalitis……………………………….…

Rabies…………………………. Hepatitis A………………………. BCG…………………….
Malaria/Malarone……………………………… Mefloquine…………………………….……
Proguanil……………………………………. Chloroquine……………………………….…

Influenza…………………………………………. Pneumovax……………………………….…
8. Did you have any ill effects following previous medication / vaccinations? Yes / No
If yes, what were these……………………………………………………………………………….

9. Ladies Do you think you are pregnant? Yes / No
Are you breastfeeding? Yes / No
What type of contraception do you use? ………………………………………………….

10. Do you have any allergies? Yes /No Do you have an allergy to Eggs? Yes / No
11. Have you had Depression? (for malaria prophylaxis) Yes / No
12. Do you suffer from Epilepsy? (for malaria prophylaxis) Yes / No
13. Have you had any injections in the last three weeks? Yes / No
14. Are you well at the moment? Yes / No
15. Have you had any organ transplant / immuno suppresent ie. chemotherapy? Yes / No
PLEASE NOTE
It may take 2 – 4 weeks after vaccinations to achieve the “maximum” protection. Please attend for all
your immunisations at least 1 month prior to travel.
NOTES FOR NURSES : Travel Plan Advice given Yes / No
Leaflets given Yes / No
No Mefloquine for patients who suffer with cardiac conduction or are taking beta-blockers.
No Doxycycline for patients who are pregnant or breastfeeding. Patients who take oral contraceptives should also use an
alternative form of contraception, eg. condoms for the remainder of cycle.
CONSENT FOR HOLIDAY VACCINATIONS
I have been advised in the requirement of vaccinations and give / do not give my consent to receive all
which are necessary.
I also understand that I am required to wait in the surgery for 20 minutes following the vaccinations.
Signed …………………………………………………… Date………………………………………….

Source: http://www.practiceonebridlington.co.uk/website/B81070/files/PracticeOneTRAVELQUESTIONNAIRE.pdf